Body System Evaluation Survey - 2.0

Body System Evaluation Survey
Name*

First NameLast Name
Email*
example@example.com
Please allow yourself approximately 5 - 15 minutes to complete the survey, answer questions based on your symptoms over the last 9 to 12 months.

Please Fill in the Following Questions by Selecting one of the Options Below:
- 0= Does not apply
- 1= Mild, or rarely occurring
- 2= Moderate or regularly occurring
- 3= Severe or occurring often
1- Do you feel fatigued or general weakness*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
2- Frequent illness/infections*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
3- Do you have a high stress life?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
4- Do you smoke?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
5- Bad breath and / or body odor*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
6- Bags under eyes*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
7- Crave sugars, bread, alcohol*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
8- Allergies, food or chemical sensitivities?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
9- Poor concentration or memory*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
10- Difficulty digesting certain foods or Belching or burping after meals*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
11- Skin/ complexion problems*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
12- Regular use of dairy products*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
13- Alcohol consumption more than one glass per week?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
14- Frequent mood swings Depressed and / or irritable*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
15- Do you consume animal meat products 5 days or more per week?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often

Body System Evaluation Survey
16- Nervousness / anxiety/ tension / worry ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
17- Insomnia / restless sleep?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
18- Muscle cramps?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
19- Sleepy when sitting up?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
20- Cold hands and feet or generally looking to warm up?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
21- Varicose veins?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
22- Frequent yeast / fungus problems?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
23- Bones break easily, osteoporosis?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
24- Excessive mucus?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
25- Physically out of shape, Short of breath climbing stairs ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
26- Tingling in lips, fingers,arms, legs?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
27- Chest pains?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
28- Very rapid or slow heartbeat?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
29- Constipation or hard bowel movements?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
30- Recurrent bladder infections, Frequent need to urinate?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often

Body System Evaluation Survey
31- Female: menstrual cramps, PMS, Menopause, hot flashes ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
32-Difficult urination?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
33- Swollen glands, puffy throat?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
34- Lower abdominal pain?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
35- Sinus inflammation/discharge?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
36- Rheumat Arthritis or any other inflammatory disorder*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
37- Sudden weight gain / loss?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
38- Headaches / Migraines?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
39- Lower back pain?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
40- Dry , flaky, skin, hair loss, brittle finger nails ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
41- Chronic cough ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
42- Water retention ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
43- Low sex drive?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
44- Constant hunger?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
45- Poor wound healing?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often

Body System Evaluation Survey
46- Muscle loss?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
47- Do you have fuzzy or coated debris on tongue?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
48- Have you had cancer at anytime?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
49- Female: Taking birth control ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
50- Do you use antacids or aspirin or ibuprofen ?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
51- Restless legs at night?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
52- Wake from sleep to urinate?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
53- Anemia that is unresponsive to iron?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
54- Are you a mouth breather?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
55- Do you have a fear of new things?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
56- Do you often have bizarre, vivid or nightmarish dreams?*

Does not applyMild, or rarely occurringModerate or regularly occurringSevere or occurring often
Calculations
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
Highest
Imbalance:
Scroll to top of page after submitting survey to receive your results
Should be Empty: