Body Chemistry

CONFIDENTIAL Balancing Body Chemistry Health Assessment

Thank you for being a valued client of Springer Chiropractic and MyVites.com.

This free and completely confidential health assessment is available to all clients of Springer Chiropractic and MyVites.com. Once you fill out and submit this assessment, it will be scored and we will contact you by phone with your results. You may re-take this assessment at any time to track your health progress or if you have a new health concern that you wish to be addressed. Please contact us at 1 (866) 551-8487 or email at [email protected] with any questions.

Balancing Body Chemistry Health Assessment

Please fill out this assessment as completely as possible. Once we receive your assessment, we will score it and give you a call with your results. (All * below fields are required.)

Name*

First

Last

Date*

Phone*

Email*

What is your physical sex?*

Male

Female

Age*

1/5

PART I

Check any of the following medications you are taking:

Antacids

Antibiotics/antifungals

Antidepressants

Antidiabetic/Insulin

Aspirin/Tylenol

Chemotherapy

Cortisone Anti-Inflammatories

Diuretics

Heart Medications

High Blood Pressure

Hormones

Laxatives

Lithium

Oral Contraceptives

Radiation

Relaxants/Sleeping Drugs

Thyroid

Ulcer Medication

Recreational Drugs (specify below)

Other (specify below)

Details of other medications or drugs:

Check if you eat, drink or use:

Alcohol

Candy

Carbonated beverages

Cigarettes

Coffee

Distilled water

Fluoridated/chlorinated water

Fast food regularly

Fried foods

Refined White flour products

Luncheon meats

Margarine

Refined sugars

Milk products

Artificial sweeteners

Non-herbal teas

Chew tobacco

Vitamins and Minerals you take. Specify:

Check if you do any of the following:

Diet Often

Salt Food without testing

Exercise less than 3 times a week

Are under excessive stress

Are exposed to chemicals at work

Are exposed to cigarette smoke

PART II
IMPORTANT

Dear Patient, please list your five major health concerns in order of importance

PART III

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

CATEGORY 1

Section A

1. Bad breath, halitosis

2. Loss of taste for high protein foods

3. Burning (“acid” or nervous stomach, eating relieves

4. Gas shortly after eating

5. Indigestion ½ to 1 hour after eating, may last 3-4 hours

6. Difficulty digesting fruits or vegetables; undigested foods found in stools

7. Acid or spicy foods upset stomach

Section B

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

8. Lower bowel gas and/or bloating several hours after eating

9. Feet burn

10. “Whites” of eyes (sclera) yellow

11. Dry skin, itchy feet and/or skin peels on feet

12. Brown spots or bronzing of skin

13. Bitter metallic taste in mouth

14. Blurred vision

15. Headache over eyes

16. Feel nauseous, queasy or gag easily

17. Color of stools light brown or yellow

18. Greasy or high fat foods cause distress

19. Pain between shoulder blades

20. Dark circles under eyes

21. “Acid” breath

22. History of gallbladder attacks, gallstones OR

22. CONT. Gallbladder removed?

Yes

23. Appetite reduces

Section C

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

24. Coated tongue or “fuzzy” debris on tongue

25. Pass large amounts of foul-smelling gas

26. Irritable bowel or mucous colitis

27. Constipation, diarrhea alternating or stools alternate from soft to watery

28. Bowel movements painful or difficult, constipation, and/or laxatives used

29. Burning or itching anus

CATEGORY 2

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

30. Head congestion/”sinus fullness”

31. Sneezing attacks

32. Dreaming, nightmare-like dreams

33. Milk products and/or wheat products cause distress

34. Eyes and nose watery

35. Eyes swollen and puffy

36. Pulse speeds after meals and/or heart pounds after retiring

CATEGORY 3

Section A

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

37. Crave sweets or coffee in the afternoon or mid-morning

38. Hungry between meals or excessive appetite

39. Overeating sweets upsets

40. Eat when nervous

41. Irritable before meals

42. Get “shaky” or light-headed if meals delay

43. Fatigue, eating relieves

44. Heart palpitates if meals are missed or delays

45. Awaken a few hours after sleep, hard to get back to sleep

Section B

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

46. Muscle soreness after moderate exercise

47. Vulnerability to insect bites (especially fleas and mosquitos)

48. Loss of muscle tone or “heaviness” in arms

49. Enlarged heart and/or heart failure

50. Worrier, feel insecure and/or highly emotional

51. Pulse slow/below 65 or irregular pulse

Yes

CATEGORY 4

Section A

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

52. Sex drive increased

53. “Splitting” type headaches

54. Memory failing

55. Tolerance for sugar reduced

Section B

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

56. Sex drive reduced or absent

57. Abnormal thirst

58. Weight gain around hips or waist

59. Tendency to ulcers or colitis

60. Increased ability to eat sugar without symptoms

61. Menstrual disorders (women)

62. Lack of menstruation (young girls)

Section C

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

63. Difficulty gaining weight, even if large appetite

64. Heart palpitations

65. Nervous, emotional, and/or can’t work under pressure

66. Insomnia

67. Inward trembling

68. Night sweats

69. Fast pulse at rest

70. Intolerant to high temperatures

71. Easily flushed

Section D

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

72. Difficulty losing weight

73. Reduced initiative and/or mental sluggishness

74. Easily fatigued, sleepy during the day

75. Sensitive to cold, poor circulation (cold ands and feet)

76. Dry or scaly skin

77. “Ringing” in ears/noises in head

78. Hearing impaired

79. Constipation

80. Excessive falling hair and/or coarse hair

81. Headaches when awaken/wear off during the day

Section E

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

82. Blood pressure increased

83. Headaches

84. Hot flashes

85. Hair growth on face or body (Question to females)

86. Masculine tendencies (Question to females)

Section F

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

87. Blood pressure low

88. Crave salt

89. Chronic fatigue/get drowsy

90. Afternoon yawning

91. Weakness/dizziness

92. Weakness after colds/slow recovery

93. Circulation poor

94. Muscular and nervous exhaustion

95. Subject to colds, asthma, bronchitis (respiratory disorders)

96. Allergies and/or hives

97. Difficulty maintaining manipulative correction

98. Arthritic tendencies

99. Nails weak, ridged

100. Perspire easily

101. Slow starter in the morning

102. Afternoon headaches

CATEGORY 5

Section A

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

103. Frequent skin rashes and/or hives

104. Muscle-leg-toe cramping at rest and/or while sleeping

105. Fever easily raised/fevers common

106. Crave chocolate

107. Feet have bad odor

108. Hoarseness frequent

109. Difficulty swallowing

110. Joint stiffness after rising

111. Vomiting frequent

112. Tendency to anemia

113. “Whites” of eyes (sclera) blue

114. “Lump” in throat

115. Dry mouth-eyes-nose

116. White spots on fingernails

117. Cuts heal slowly and/or scar easily

118. Reduced or “lost” sense of taste and/or smell

119. Susceptible to colds, fevers and/or infections

120. Strong light irritates eyes

121. Noises in head or ringing in ears

122. Burning sensations in mouth

123. Numbness in hands and feet (extremities “go to sleep”)

124. Intolerant to monosodium glutamate (MSG)

Yes

125. Cannot recall dreams

126. Nose bleeds frequent

127. Bruise easily, “Black and blue” spots

128. Muscle cramps, worse with exercise “”charley horses”)

CATEGORY 6

129. Aware of heavy and/or irregular breathing

130. Discomfort in high altitudes

131. “Air hunger”/sign frequently

132. Swollen ankles/worse at night

133. Shortness of breath with exertion

134. Dull pain in chest and/or pain radiating into left arm, worse on exertion

2/5

CATEGORY 7

Males: Skip to next page.

Female Only

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

135. Premenstrual tension

136. Painful menses (cramping, etc.)

137. Menstruation excessive or prolonged

138. Painful/tender breasts

139. Menstruate too frequently

140. Acne, worse at menses

141. Depressed feelings before menstruation

142. Vaginal discharge

143. Menses scanty or missed

144. Hysterectomy/ovaries removed

Yes

145. Menopausal hot flashes

146. Depression

3/5

CATEGORY 8

Females: Skip to next page.

Male Only

Directions: Please read each description and select the number that best represents the frequency of your symptoms within the past year.

0 = Never
1 = Mild (Occurs once a month or less)
2 = Moderate (Occurs several times monthly)
3 = Severe (Aware of it almost constantly)

147. Prostate trouble

148. Urination difficult or dribbling

149. Night urination frequent

150. Pain on inside of legs or heels

151. Feeling of incomplete bowel evacuation

152. Leg nervousness at night

153. Tire easily/avoid activity

154. Reduced sex drive

155. Depression

156. Migrating aches and pains

4/5

Now that you've answered as many questions as possible, feel free to use the PREVIOUS button to review your answers as much as you need, then press SUBMIT RESPONSES to send them to the doctor for review. Any of your responses in this form will only be used internally, we do not send them to any third party.

5/5

*Your privacy is of the utmost importance and none of the information we collect is ever sold or shared with others. When you fill out the questions and send it to us, we must ask you for certain personal information so that we can provide your personalized results. We will use your email address to communicate any specials and other information designed to improve your experience and save time and money with the MyVites.com site. At any time, you may unsubscribe by following the “unsubscribe” link in any such email, or by sending us an email request to remove your name from the list. The personal details collected during the evaluation process will not be shared or used in any other way. Please see our Privacy Policy for more information.

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CONFIDENTIAL Balancing Body Chemistry Health Assessment

PART I

PART II
IMPORTANT

PART III

CATEGORY 1

Section A

Section B

Section C

CATEGORY 2

CATEGORY 3

Section A

Section B

CATEGORY 4

Section A

Section B

Section C

Section D

Section E

Section F

CATEGORY 5

Section A

CATEGORY 6

CATEGORY 7

Female Only

CATEGORY 8

Male Only

Featured Brands

Select Your Brand

CONFIDENTIAL Balancing Body Chemistry Health Assessment

PART I

PART IIIMPORTANT

PART III

CATEGORY 1

Section A

Section B

Section C

CATEGORY 2

CATEGORY 3

Section A

Section B

CATEGORY 4

Section A

Section B

Section C

Section D

Section E

Section F

CATEGORY 5

Section A

CATEGORY 6

CATEGORY 7

Female Only

CATEGORY 8

Male Only

PART II
IMPORTANT