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Health Survey

HEALTH SURVEY

*Name: *Age:                    *required *Phone:  Work Phone: *Address:  City: *State:  Zip: *Occupation: *# Hours/week currently working  Spouse Occupation:  # Hours/week currently working

Disclaimer: I am of legal age and I understand and acknowledge that: Dr. Kingsbury's Health Support Program is presented for educational purposes only and is not intended to diagnose or treat illness, disease or any other medical condition. Dr. Kingsbury's Health Support Program is designed to present information in support of a healthy lifestyle, but does not guarantee an illness-free life. I agree that, as a Participant, it is solely my responsibility to consult with a licensed professional whom I trust to: Determine whether this program is suitable for me. Review any special health concerns, risk factors or medical conditions, especially if I am pregnant, lactating, or currently suffering any health condition, and determine whether any of the foods, phytochemicals, supplements, nutrients, products, appliances, or physical and mental exercises recommended or presented is appropriate in the specified amounts, or is contraindicated for me as an individual.

Rate each of the following symptoms based upon your health profile for the past 30 days. By taking this test, you affirm that you have read, understand and agree to the disclaimer.

Rate each symptom on a scale of 0 to 4 based on the chart on the right POINT SCALE: 0 = never or almost never have the symptom 1 = occasionally have it, effect is not severe 2 = occasionally have it, effect is severe 3 = frequently have it, effect is not severe 4 = frequently have it, effect is severe

DIGESTIVE SYSTEM 0 1 2 3 4 Nausea or vomiting 0 1 2 3 4 Diarrhea 0 1 2 3 4 Constipation 0 1 2 3 4 Bloated feeling 0 1 2 3 4 Belching, passing gas 0 1 2 3 4 Heartburn   EARS 0 1 2 3 4 Itchy ears 0 1 2 3 4 Earaches, ear infection 0 1 2 3 4 Drainage from ear 0 1 2 3 4 Ringing in ears, hearing loss   EMOTIONS 0 1 2 3 4 Mood swings 0 1 2 3 4 Anxiety, fear, nervousness 0 1 2 3 4 Anger, irritability 0 1 2 3 4 Depression   ENERGY/ACTIVITY 0 1 2 3 4 Fatigue, sluggishness 0 1 2 3 4 Apathy, lethargy 0 1 2 3 4 Hyperactivity 0 1 2 3 4 Restlessness   EYES 0 1 2 3 4 Watery, itchy eyes 0 1 2 3 4 Swollen, reddened or sticky eyelids 0 1 2 3 4 Dark circles under eyes 0 1 2 3 4 Blurred/tunnel vision   HEAD 0 1 2 3 4 Headaches 0 1 2 3 4 Faintness 0 1 2 3 4 Dizziness 0 1 2 3 4 Insomnia   HEART 0 1 2 3 4 Skipped heartbeats 0 1 2 3 4 Rapid heartbeats 0 1 2 3 4 Chest pain   JOINTS / MUSCLES 0 1 2 3 4 Pain or aches in joints 0 1 2 3 4 Arthritis 0 1 2 3 4 Stiffness, limited movement 0 1 2 3 4 Pain, aches in muscles 0 1 2 3 4 Feeling of weakness or tiredness

LUNGS 0 1 2 3 4 Chest congestion 0 1 2 3 4 Asthma, bronchitis 0 1 2 3 4 Shortness of breath 0 1 2 3 4 Difficulty breathing   MIND <