Instructions: Please read the questions below and put a CHECK (these are not YES and NO answers) in front of the questions which most accurately describe you and the symptoms you normally experience. Many of the questions will seem similar to you and are included to assure accuracy of test results.

Part 1
1. Do you have trouble judging distances while driving at night?
2. Do you have little bumps on your upper arm?
3. Do your eyes ever burn or itch?
4. Do you have poor immunities, getting sick frequently?
5. Is acne or tearing cuticles a problem for you?
6. Have you gotten a new wart(s) in the last six months?
7. Do you pass blood clots or hemorrhage during your menstrual period?

Part 2
1. Do you have a general lack of energy?
2. Do your lips crack, chap, or feel dry frequently?
3. Do you feel tired when you get up in the morning?
4. Do your feet smell when you take off your socks?
5. Do you eat chocolate or drink more than 2 cups of coffee daily?
6. Females - Do you currently use synthetic estrogen or birth control pills?
7. Do you have pucker marks on your upper lip?

Part 3
1. Do you bruise easily?
2. Do your gums bleed when you brush or floss?
3. Do you have varicose veins?
4. Do you ever get nosebleeds?
5. Do you smoke cigarettes?
6. Do you have any bruises right now?

Part 4
1. Do you ever get leg cramps, "Charlie horses" or menstrual cramps?
2. Do you have muscle spasms?
3. Do you feel nervous or irritable at times?
4. Do you ever break bones?
5. Do you have difficulty sleeping well?

Part 5
1. Do you ever experience shooting pains in you left arm?
2. Have you ever had a heart attack or a stroke?
3. Do your hands or feet fall asleep easily?
4. Do you ever have blood clots or varicose veins?
5. Females - Are you infertile, on birth control pills or menopausal?
6. Males - Have you lost your sex drive?
7. Do you have high cholesterol, triglycerides, or blood pressure?

Part 6
1. Do you have problems with water retention?
2. Have you ever had kidney stones?
3. Do you get occasional sores in your mouth?
4. Females - Is Premenstrual Tension a problem for you?
5. Do you experience motion sickness easily?
6. Do you have a high cholesterol level?

Part 7
1. Do you generally have a poor appetite?
2. Are you anemic?
3. Are you a vegetarian, seldom eating flesh foods?
4. Do you feel fatigued or depressed frequently?
5. Do you have poor digestion?
6. Do you feel as if your concentration and memory are failing?
7. Is your tongue sore sometimes?

Part 8
1. Do you smoke cigarettes daily?
2. Do you catch infections frequently?
3. Do you have allergies?
4. Have you ever had cataracts?
5. Do your wounds, cuts, and bruises heal slowly?
6. Do you have loose teeth or gums that bleed when you brush or floss?
7. Do you get frequent sore throats?

Part 9
1. Do you have dark circles under your eyes?
2. Do you ever experience rectal itching?
3. Do you grind your teeth at night or sometimes pick your nose?
4. Do you have any house pets?
5. Have you ever traveled to a "Third-World" country?
6. Have you ever been diagnosed as having parasites?
7. Do you ever eat pork products - ham, bacon, pork chops, pork ribs?

Part 10
1. Do you burp after eating?
2. Do you have bad breath frequently?
3. Do you need to use antacids occasionally?
4. Do you sometimes feel bloated after a meal?
5. Do you frequently have gas?
6. Do you have a low appetite level?
7. Do you occasionally experience heartburn?

Part 11
1. Do you have leg cramps, "Charlie horses" or menstrual cramps?
2. Are you suffering from gum disease?
3. Do you have arthritis or osteoporosis of any kind?
4. Do you have achy or swollen joints?
5. Turn your neck from side to side--do you hear a cracking/scraping noise?
6. Do you ever have muscle spasms?

Part 12
1. Do you feel tired much of the time?
2. Do your fingernails split or peel horizontally?
3. Do you have dark circles under your eyes much of the time?
4. Are you just as tired when you wake up as when you went to bed?
5. Have you ever been told you were anemic?
6. Do your cheeks seem to have lost a natural, rosy color?
7. Do you drink more than 2 cups of coffee or black tea daily?

Part 13
1. Do you have an irregular heartbeat?
2. Do you need to use laxatives or experience diarrhea frequently?
3. Do you have weak muscles or do your muscles cramp?
4. Do you use Licorice Root herb daily?
5. Do you occasionally feel slightly shaky, light headed, "spacey", or "on edge"?
6. Do you have sluggish intestines with gas accumulations?
7. Do you use diuretics (drugs, not herbs)?

Part 14
1. Do you have little white specks on your fingernails?
2. Do heal slowly when you cut yourself?
3. If you are male, do you have trouble voiding completely?
4. If you are male, do you urinate frequently during the day or several times at night?
5. Do you have diabetes?
6. Have you had a loss of sense of taste, smell, or hearing?

Part 15
1. Do you sometimes experience constipation (less than one bowel elimination a day)?
2. Do the bottoms of your feet hurt when you first get out of bed in the morning?
3. Do you take a fiber supplement daily? Check this IF THE ANSWER IS NO.
4. Do you occasionally have intestinal gas or sharp pains in your abdomen (below your waist)?
5. Do you have loose stools or diarrhea frequently?
6. Are your stools either watery or quite hard?

Part 16
1. Do you have kidney or gall stones?
2. Do you use alcohol on a daily basis?
3. Do you have muscle tremors, leg cramps, or muscle spasms?
4. Are you menopausal or post-menopausal or do you have osteoporosis?
5. Are you ever bothered by nervous twitches or "ties" or feel very nervous at times?
6. Do you have heart disease or cardiac arrhythmias?

Part 17
1. Does you tongue or mouth get sore occasionally?
2. Do you have Herpes of the mouth or genitalia?
3. Do you ever get canker sores or cold sores?
4. Do you ever get unexplained skin rashes, fungus infections, vaginitis or "jock itch", or recurring kidney/bladder infections?

Part 18
1. Do you have stomach or duodenal ulcers?
2. Do you have a hiatal hernia or do you experience a burning sensation in the throat or chest when you lie down?
3. Is it hard to eat a meal without feeling an upset stomach?
4. Do you feel nauseated when you are nervous or hungry?
5. Do you sometimes have heartburn?
6. Do you experience pains in your stomach for which you use antacids occasionally?

Part 19
1. Do you have trouble digesting fats?
2. Do you have a high cholesterol or triglyceride level?
3. Do you have heart trouble?
4. Do you have high blood pressure?

Part 20
1. Do you have cold hands & feet?
2. Are you extremely uncomfortable when it is quite cold?
3. Would you like to be able to take a nap in the middle of the afternoon?
4. Do your fingers tremble when you hold them straight out?
5. Is your hair dry & brittle or thin?
6. Does your heart beat very fast after exerting yourself!
7. Do you gain weight easily?
8. Are you uncomfortable when it is very hot?

Part 21
1. Do you get extremely thirsty frequently?
2. Do you have mood swings, feeling fine one moment and "down in the dumps" the next?
3. When you cut yourself, do you heal very slowly?
4. Do you feel that you urinate large amounts?
5. Have you ever been diagnosed as having diabetes?
6. Does your breath ever smell sweet?

Part 22
1. Do you feel like you often have mood swings?
2. Do you have a problem with motion sickness?
3. Do you feel like you have low energy much of the time?
4. Do you crave sweets, cigarettes, coffee or cola drinks between meals?
5. Do you have low blood pressure?
6. Do you often feel shaky or confused?
7. Do you have low blood sugar or hypoglycemia?
8. Do you have a weight problem?

Part 23
1. Are your hands and feet often cold or do they "fall asleep" easily?
2. Have you had a stroke or heart attack?
3. Are you ever aware of your heart beating irregularly?
4. Do you feel breathless when you exert yourself!
5. Do your ankles swell toward the end of the day or do your legs feel heavy?
6. Have you ever had high blood pressure?
7. Do you have varicose veins or hemorrhoids?
8. Do you feel as if it is getting harder to remember or concentrate?

Part 24
1. Do you feel nervous and anxious much of the time?
2. Do little things make you crabby or grouchy?
3. Do you worry about what others think of you?
4. Do your hands shake when you are excited or upset?
5. Do you experience insomnia frequently?
6. Are you very concerned about your appearance and/or your house?
7. Do you consider yourself an "over-achiever"?

Part 25
1. Is it hard for you to catch your breath when exerting yourself!
2. Do you smoke cigarettes?
3. Are you a shallow breather?
4. Do you have respiratory allergies or asthma?
5. Do you have a chronic cough, sore throat, or mucous?
6. Do you catch colds or sinus infections easily?

Part 26
1. Do you tolerate fats in your diet poorly?
2. Do you frequently have gas or bloating after eating?
3. Do you ever have pain on the right side under your rib cage or between your shoulder blades?
4. Do you have gallbladder trouble or have you had gallbladder surgery?
5. Have you ever had or do you have hepatitis?
6. Females: do you have have fibroids, hemorrhaging, hot flashes, or menstrual problems?
7. Do you have symptoms of ill-health that the doctors tell you they can't diagnose.
8. Are you often fatigued or feel "hung-over" when you wake up in the morning?

Part 27
1. Do you ever experience back-aches in the waist area?
2. Do you ever suffer from kidney or bladder infections?
3. Do you retain water?
4. Do you have frequent or painful urination?
5. Are your feet or ankles swollen at the end of the day?
6. Do you have high blood pressure?

Part 28
1. Do you have repeated or chronic sinus congestion, sinus infections, or upper respiratory (lung/bronchial) problems?
2. Do you have vaginal itching or discharge frequently (females) or "jock itch" (males)?
3. Have you recently had or do you currently have a fungus infection or Athletes' Foot?
4. Do you get frequent or recurring bladder, kidney, or prostate infections?
5. Have you ever had thrush in your mouth or any unexplained skin rashes that come and go?
6. Did you use antibiotics, sulpha drugs, steroids, or birth control pills previous to the occurrence of the above problems? (Do not check #6 unless you have checked at least one other number in Part 28)

Important: Please re-read all of the above questions and see if you missed any of your symptoms. Careful thought to the questions assures more accurate test results.