Online Assessment Form

Your Name:
Your E-mail:
Subject:       
Your primary health problems:
.

SYMPTOMS

HEAD:
Headache
entire head
back of head
forehead
temples
migraine
Head feels heavy
Loss of memory
Light-headedness
fainting
Light bother eyes
Loss of smell
Loss of taste
Loss of balance
Dizziness
Loss of hearing
Pain in ears
Ringing in ears
Buzzing in ears
 LOW BACK:
Low back pain
Low back pain is
worse when:
working
lifting
stooping
standing
sitting
bending
coughing
Pinced nerve in low back
Slipped disc
Low back feels out of place
Muscle spasms
Arthritis
 SHOULDERS:
Pain in shoulder joint (R-L)
Pain across shoulders
Bursitis (R-L)
Arthritis (R-L)
Can't raise arm
above shoulder level
over head
Tension in shoulder (R-L)
Muscle spasm in shoulders
 HIPS, LEGS, FEET:
Pain in Buttocks (R-L)
Pain in hip joint (R-L)
Pain down leg (R-L)
Pain down both legs
Leg cramps
Pins and needles in legs (R-L)
Numbness of leg (R-L)
Numbness of feet (R-L)
Numbness of toes
Feet feel cold
Cramps in feet (R-L)
Swollen ankles (R-L)
Swollen feet (R-L)
Painful joints in toes
Pain foot (R-L)
Pain in knee (R-L)

NECK:
pain in neck
Neck pain with movement
Pinced nerve in neck
Neck feels out of place
Stiff neck
Muscle spasms in neck
Grinding sounds in neck
Grating sounds in neck
Popping sounds in neck
Arthritis in neck
 MID-BACK:
Mid back pain
Pain between shoulder blades
Sharp stabbing pain in mid-back
Muscle spasms

ABDOMEN:
Nervous stomach
Nausea
Gas
Constipation
Diarrhea

 ARMS & HANDS:
Pain in upper arm
Pain forearm
Pain in hands
Pain in fingers
Pinced nerve in arm
Pinced nerve in fingers
Sensation of pins & needles in arms
Sensation of pins & neddles in fingers
Fingers go to sleep
Hands cold
Swollen joints in fingers
Sore joints in fingers
Arthritis in fingers
Loss of grip strength
 CHEST:
Chest pain
Shortness of breath
Pain around ribs

GENERAL:
Nervousness
Irritable
Depressed
Fatigue
Feel run-down
Loss of sleep
Loss of weight

Have you had X-rays before? Yes No     When?
What areas were X-rayed?
Results of X-rays
WOMEN ONLY: Menstrual pain Cramping Irregularity     Date of last period
Are you pregnant? Yes No     How long?
Are you on medication? Yes No     What medication?     If yes, how long?
How old are you?     Occupation?     Length of disease

NOTE: This Online assessment is only FREE for clients
who will purchase herbal formulas Cessiac and Yuccalive
and will apply the meditation techniques and nutrition guidelines.

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