*Comprehensive Health Evaluation (Male)

Comprehensive Health Evaluation
Serotonin
1. Feel depressed, unhappy, or sad

NoMildModerateSevere
2. You can’t stay asleep and/or lack of deep restorative sleep

NoMildModerateSevere
3. Compulsive behavior, unprovoked anger and/or unexplained crying

NoMildModerateSevere
Serotonin %
Dopamine
4. Feel anxious or have social phobia

NoMildModerateSevere
5. Have addictive personality; Past/present troubles with alcohol, food, pharmaceutical and recreational drugs.

NoMildModerateSevere
6. Have troubles staying focused on one particular task

NoMildModerateSevere
7. Life seems less fun, colorful or flavorful, lack pleasure

NoMildModerateSevere
Dopamine %
Acetylcholine
8. Lapses in memory

NoMildModerateSevere
9. Difficulty comprehending verbal instructions

NoMildModerateSevere
Acetylcholine %
Gaba
10. Feel tense and/or have troubles turning your mind off when you want to relax

NoMildModerateSevere
11. Feel irritable, crabby or short tempered

NoMildModerateSevere
12. You often use alcohol or other sedatives to calm down

NoMildModerateSevere
Gaba %
Stress
13. Feelings of hopelessness

NoMildModerateSevere
14. Feelings of being overwhelmed

NoMildModerateSevere
15. Events from the past cause you pain, resentment or anger

NoMildModerateSevere
16. Worry about the future or current situation you are in (finances, health, work, family, lack of purpose, lack of certainty)

NoMildModerateSevere
17. Current level of stress

NoMildModerateSevere
Stress %
Nervous System Total %
Adrenal Glands
18. Stress seems to easily cause noticeable symptoms like flushing or heart palpitations

NoMildModerateSevere
19. Brain fog, forgetting basic things, a sense of mild confusion Stress seems to easily cause noticeable symptoms like flushing or heart palpitations

NoMildModerateSevere
20. Unexplained anxiety

NoMildModerateSevere
21. Low or high blood pressure

NoMildModerateSevere
22. Troubles falling asleep and/or wakes up after 2-4 hours of sleep and unable to fall back asleep within 30 minutes

NoMildModerateSevere
23. Alternating areas of pain, tenderness, hot, sore, and sensitive to the touch or diagnosed with chronic fatigue syndrome or fibromyalgia

NoMildModerateSevere
Adrenal Glands %
Thyroid Gland
24. Hands and feet frequently feel cold or chilled

NoMildModerateSevere
25. Constantly feeling sleepy

NoMildModerateSevere
26. Feel slow-moving, sluggish

NoMildModerateSevere
27. Constipated regularly

NoMildModerateSevere
28. Dry or scaly skin

NoMildModerateSevere
29. Hair feels coarse and/or brittle

NoMildModerateSevere
30. Losing hair and/or outer third of eyebrow

NoMildModerateSevere
31. Heavy menstrual periods (men answer no)

NoMildModerateSevere
32. Weight gain despite changes in diet

NoMildModerateSevere
33. Take thyroid medication

NoYes
Thyroid Gland %
Male Hormones
34. Decrease in muscle mass, with an increase in body fat

NoMildModerateSevere
35. Loss of sex drive

NoMildModerateSevere
36. Suffer from erectile dysfunction

NoMildModerateSevere
37. After 35 years of age started having troubles concentrating and/or lack of feeling sharp

NoMildModerateSevere
38. Unexplained depression and decreased since of wellbeing after 35 years of age

NoMildModerateSevere
Male Hormones %
Hormonal System Total (Male) %
Stomach Function
39. Indigestion, taste or burp food hours after eating

NoMildModerateSevere
40. Low iron/anemia

NoYes
41. Use antacids or take medications for digestion

NeverOnce or twice weeklyThree to five times weeklyDaily
Stomach Function %
Gastrointestinal Inflammation
42. Feel a sense of nausea when you eat or before you eat

NoMildModerateSevere
43. Stomach pain relieved by eating food, drinking carbo-nated beverages, milk, or taking antacids

NoMildModerateSevere
44. Indigestion after eating may be 30 to 90 minutes after eating

NoMildModerateSevere
45. Muscle twitching

NoMildModerateSevere
Gastrointestinal Inflammation %
Small Intestines and Pancreas
46. Pain under your rib cage on your left side

NoMildModerateSevere
47. Indigestion is delayed, occurring 2-4 hours after eating a meal

NoMildModerateSevere
48. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day

NoMildModerateSevere
49. Excessive odor with bowel movements

NoMildModerateSevere
50. Undigested food in your bowel movements

NoMildModerateSevere
51. Diarrhea or frequently loose stools

NoMildModerateSevere
Small Intestines and Pancreas %
Large intestines
52. Discomfort, pain or cramps in your lower abdominal area

NoMildModerateSevere
53. Eating raw fruits and vegetables causes gas, bloating, and pain in lower abdomen

NoMildModerateSevere
54. Anal itch

NoMildModerateSevere
Large intestines %
Gallbladder
55. Bowel movements alternate from normal to clay colored

NoMildModerateSevere
56. Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side

NoMildModerateSevere
57. History of gallstones or attacks, had gallbladder removed (if yes answer severe)

NoMildModerateSevere
Gallbladder %
Nutritional Deficiency
58. Muscle cramping

NoMildModerateSevere
59. Ridges on nails, longitudinal

NoMildModerateSevere
60. Gingivitis, gums bleeding

NoMildModerateSevere
61. Anorexia or bulimia

NeverWithin last 5 yearsWithin last 2-5 yearsCurrently or within last 2 years
62. Cracking/peeling/brittle/splitting fingernails or fingertips (i.e. hang nails)

NoMildModerateSevere
63. Small bumps on back of upper arms and/or thighs

NoMildModerateSevere
Nutritional Deficiency %
Immune Function
64. Suffer from eczema, psoriasis, lupus, MS, RA, Crohn’s or any other autoimmune condition

NoYes
65. Recurrent thrush or fungal infections

NoYes
66. Used intravenous antibiotics to clear infection or taken antibiotics for more than 30 days continuously

NoYes
67. Frequency of sinus, ear, yeast, kidney, bladder, skin and lung infections

None2 to 3 times per year4 to 5 times per year6 or more times per year
68. Frequent colds or flu

None2 to 3 times per year4 to 5 times per year6 or more times per year
69. Suffer from allergies

NeverRarelyOccasionallyOften
Immune Function %
Digestive System Total %
Detoxification system
70. Currently taking statin medication or history/currently elevated cholesterol

NoYes
71. Suffer from acne, liver spots, or other skin lesions

NoMildModerateSevere
72. Suffer migraines and/or headaches frequently

NoMildModerateSevere
73. Bitter or metallic taste

NoMildModerateSevere
74. Difficulty recalling commonly used words

NoMildModerateSevere
75. Excessively strong body odor

NoMildModerateSevere
76. Yellowish tint of the whites of your eyes

NoMildModerateSevere
77. Dark circles around your eyes

NoMildModerateSevere
Detoxification System %
Total Wellness Score Male %
Please list your top 5 complaints. If you don’t have 5 that is okay.
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Comprehensive Health Evaluation

Serotonin

Dopamine

Acetylcholine

Gaba

Stress

Adrenal Glands

Thyroid Gland

Male Hormones

Stomach Function

Gastrointestinal Inflammation

Small Intestines and Pancreas

Large intestines

Gallbladder

Nutritional Deficiency

Immune Function

Detoxification system

Please list your top 5 complaints. If you don’t have 5 that is okay.

Contact Information