NutriZen Questionaire

Would you like to be notified of herbs and other nutrients that might help you with your specific health problems? Yes No [ If No, don't bother filling out the form. ]

Disclaimer: Almost every bodily function is capable of improvement with a higher quality biochemical environment. This even means behavior, and thinking ability, because these are really caused by biochemicals in the brain.

While I can try to teach you, and steer you to the right nutrients or herbs that MAY help, there is not any claim of selling you a CURE.  You have to learn how to take charge of your own health care decisions, and learn to research EVERYTHING before you try it. Make one change at a time, so that you can tell if it helps or not.

My role here is more of a consultant and teacher,       and the herbs and nutrients are just tools to this learning experience.

With something new,   always start slowly, and try one capsule, and see how you feel. If it did not do any good, try two capsules. In most things, two capsules is plenty to try, and see if it helps. Be SURE to read this http://www.snowcrest.net/soza/NZdata/AAINTRO.htm

Did you read this Introduction to NutriZen\BodyEquations?


 
 

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Client name 
Client address
Client city/state/zip
Client email address

Do you have dental insurance?  vision insurance? medical insurance?
Have you been under a lot of stress?         Are you unemployed? 

Digestion, Absorption, Assimilation

Dietary Habits

EXERCISE AND PHYSICAL CONDITION

Elimination

Liver Function

Kidneys and Bladder
Immune Function

Hormone Function

Heart And Circulatory Function
Lungs And Respiratory Function

Sleep
Arthritis, Rheumatism, Fibromyalgia
Headaches, Thinking, Behavior
 
 

Other Nutrients You Are Now Taking On A Regular Basis
 
 

Digestion, Absorption, Assimilation

Do you have a history of indigestion? 
Do you have any trouble (with) chewing? 
Do you have missing teeth? 
Do you have dentures? 
Do you have a jaw that gets sore? 
Do you consciously try to chew your food well? 
Do you have any trouble (with) swallowing? 
Do you have a history of stomach ulcers? 
Do you have heartburn or stomach gas? 
Do you take digestive enzymes? 
Do you have leaky gut syndrome? 
Do you have diverticulitis? 

Do you have a history of gallstones? 

Dietary Habits

Do you eat fried foods?  If yes, what fat or oil do you fry in?
Do you eat snack chips? 
Do you put butter on your vegetables? 
Do you use a lot of salad dressing? 

EXERCISE AND PHYSICAL CONDITION
Do you regularly exercise vigorously? 
Do you regularly exercise less strenuously? 
Are you feeling "out of shape"? 

Type of exercise preferred:
stretching yoga bicycling weights walking
dancing gardening hard physical work exercise class 

Do you have cellulite? 
Do you have a flat tummy? 
Do you have a pot belly? 
Do you consider yourself overweight? 
 

Elimination
Do you have constipation? 
Do you regularly use laxatives? 
Do you occasionally use laxatives? 
Do you have irritable bowel? 
Do you have frequent diarrhea? 
Do you have hemorrhoids? 
 

Liver Function
Do you have a history of liver trouble? 
Do you occasionally drink alcohol? 
Do you regularly drink alcohol? 
If you don't drink some, do you get withdrawal symptoms?
Do you regularly drink coffee? 
 
 

Kidneys and Bladder
Do you have to get up in the night to urinate? 
Do you have a history of kidney disease? 
Do you have trouble with incontinence (holding your urine)? 
Do you have bladder cancer? 
Do you have frequent bladder infections? 
Did you ever have kidney infections? 
Did you ever have kidney stones? 

Do you have a history of overweight? 
Do you have a history of water retention? 
 

Immune Function
Do you have a chronic bacterial infection, that you can't overcome? 
Do you have a chronic viral infection, that you can't overcome? 
Have you taken a lot of antibiotics? 
Do you always take acidophilous after antibiotics? 
Do you have swollen lymph glands? 
Do you have a low-grade fever? 
Do you have allergies? 
Do you have  sinusitis? 
Do youi have chemical sensitivities? 
Do you have a history of cancer? 
Are you currently battling cancer? 
Do you have a history of skin diseases? 
Do you have a history of melanoma? 
Do you have a history of skin cancer? 
Did you ever have sexually-transmitted disease? 
For females: Do you have a history of bad pap smear? 
For males: Is your prostate gland affecting your urination? 
For males:  Do you have prostate trouble? 

Hormone Function
Do you have a history of low body temperature? 
Do you have a history of bonespurs or calcium deposits? 
Do you have a history of thin or thinning hair? 
Do you have a history of fatigue? 
Do you have a history of glandular trouble? 
Have you been diagnosed as hypothyroid? 
Have you been diagnosed as hyperthyroid? 

For Females:
Are you post-menopausal? 
Are you peri-menopausal? 
Are you post-menopausal because of surgery? 
 

Arthritis, Rheumatism, Fibromyalgia
Do you have a history of back injury? 
Do you have a pinched nerve in your spine? 
Do you have a pinched nerve in your back? 
Did you ever have back surgery? 
Do you have in chronic pain now currently or in the recent past? 
Do you have arthritis currently or in the recent past? 
Do you have a history of soremuscles? 
Do you have a history of broken bones? 
Do you have a history of sprains? 
 

Heart And Circulatory Function
Do you have a history of heart trouble? 
Do you have a history of heart attack? 
Do you have a history of narrow arteries? 
Do you have a history of varicose veins? 
Do you have a history of hypertension? 
Do you have a history of stroke or transient ischemic attack (TIA)? 
Do you have a history of irregular heartbeat? 
Do you have a history of dizziness? 
Do you have a history of heart valve trouble? 
Do you have high cholesterol? 
Do you have a history of blood clots? 
Are you a "free bleeder"? 
 
 

Lungs And Respiratory Function
Do you have any trouble (with) breathing? 
Do you have a history of lung diseases? 
Do you have a history of smoking tobacco? 
Are you smoking currently? 
Do you have a history of coughing? 
Do you have asthma currently or in the recent past? 
Do you have bronchitis currently or in the recent past? 
Do you have pneumonia currently or in the recent past? 
Do you have chest xray currently or in the recent past? 
Do you regularly take antioxidant vitamins (A,E,C,Pycnogenol)? 
Are you conscious of good indoor air quality? 


 
 

Headaches, Thinking, Behavior

Do you have a history of head injury? 
Did you lose consciousness? 
Do you have a history of neck injury? 
Do you often feel nervous? 
Do you often feel anxious? 
Do you get tension headaches? 
Do you get migraine headaches? 
Do you do a lot of mental work? 
Do you have eye-strain? 
 
 
 

Sleep
Do you have any trouble (with) going to sleep? 
Do you have any trouble (with) staying asleep? 
When you wake up in the morning, do you feel refreshed? 
Are you taking any sleeping aids? 
Do you need an alarm clock to get up? 
Do you need a snack to go to sleep? 
Do you drink coffee at night? 
Do you get sleepy after eating? 
 
 

What herbs or other nutrients are you now taking on a regular basis?
 

Nutrient Name Purpose In Taking It Is It Helping?