HealthSmart Nutrition's
Program 1 (Female)
Metabolic Bio Evaluation

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HealthSmart Nutrition's Metabolic Bio Program is only available through a
Certified HealthSmart Nutrition Metabolic Bio Typing Advisor.

  • If you would like to become a HealthSmart Nutrition Metabolic Bio Typing Advisor, you can :
  • If you have already made arrangements for your Metabolic Bio evaluation through a Certified HealthSmart Nutrition Metabolic Bio Typing Advisor and have received your ID number, proceed to the steps below.

How To Complete Your Metabolic Bio Evaluation

Once you have an Advisor and are ready to proceed, there are 5 easy steps to complete this evaluation.

  • 1 - Select the pictures that best match your body
  • 2 - Fill in your information in the Vital Statistics table
  • 3 - Read and then sign the Informed Consent Form
  • 4 - Complete the Metabolic Bio Typing Evaluation
  • 5 - Submit your evaluation for analysis

After analysis, Your Results Will Be Analysed by Your Advisor -- normally within 48 business hours of receipt. Later when you receive your report you will then be able to discuss the results of your Analysis as well as your Individual Program Recommendations with your Advisor. Your Advisor will be available to you on an on-going basis to answer your questions throughout the duration of your program. This is extremely important in order for you to have guidance and understanding while on the program.


Body type Selector
Step 1: Determine what your body looks like now by clicking on the pictures that follow to receive your FREE Custom Body Remodeling Exercise booklet that is included with every Metabolic Bio Typing analysis. Pick the appropriate one that describes you by reading the descriptions provided for each section (Upper Body, Middle Body, and Lower Body). This will help in determining the conditioning exercises necessary to sculpt your body into the new you.

You won't have to spend hours in the gym trying to reshape your body because in less than half an hour 2 x's per week these exercises are targeted for the specific areas you want to work on.

You won't be wasting your time doing unnecessary exercises that are not helping you target your problem areas. These exercises do not require expensive equipment, a lot of floor space and can be done by most people of any age or physical condition (some slight modifications may be recommended by your metabolic bio typing advisor.)

Vital Statistics Table

Now you're ready to begin filling out the form . . .

To navigate through the form, you can use your mouse or you can also use your TAB key to move forward and Shift-TAB to move backwards.

Note that the following fields MUST be completed so that your form will go through when you click Submit at the end:


Date:eg, June 1, 2000
ID Number:
Last Name:
First Name:
Postal Code/Zip:
* NOTE: Please provide complete phone/fax numbers, including country code, area code
Example: 1-243-532-6472
Day Phone:*
Night Phone:*
( Are you doing a Hair Analysis with this evaluation? )
Hair Test:     
( Do you want Program 2 with this evaluation? This requires a live blood analysis )
Live/Dry Blood Analysis:
Please indicate below the reason for your interest in this program:
Body Fat % *
* Put these values in. If you didn't use the tables on the introduction page
Click here to have BMI calculated for you. Calc.BMI
Are you in Menopause?
Birthdate: eg, May 18, 1975
Height: feet' inches
Ideal Weight:
Marital Status:(S)ingle,(M)arried,(D)ivorced
This is my: (1,2,3 etc.) test.
Blood Type:
Advisor Email:
Advisor Phone:
Advisor Fax:
Advisor Cert #:
* NOTE: Please provide complete phone/fax numbers, including country code, area code
Measurements: Please take these as per diagram at left if at all possible.
Best way is without clothes
Neck: * in.
Shoulders: * in.
Chest: in.
Biceps: L in. R in.
Waist: in.
Forearms: L in. R in.
Hips: * in.
Thighs: L in. R in.
Calves: L in. R in.
*completely around
Also if possible have your blood pressure taken at resting using you left arm and fill in the blanks.
Systolic (mmHg)

Make sure that the following fields contain data in the table above. Otherwise, when you submit your form, it will NOT go

Informed Consent
Before you begin to answer your questionnaire, it is necessary that you read the following disclaimer and sign your name electronically to signify your agreement with its content. This evaluation will not be sent to us unless you sign this consent form. Thank you.
HealthSmart Nutrition's metabolic bio analysis and any accompanying individualized ecological lifestyle recommendations that may be made are based on theories drawn from the ideas of past researchers in the field (William L. Wolcott The Metabolic Typing Diet, William Kelly, George Watson, Roger Williams,Weston A. Price, Frances Pottinger, Royal Lee) and on their empirical and objective observations made from working with thousands of individuals over the past 20 years. These theories have not been scientifically proven. Thus, the accuracy of their theories or the validity of our recommendations, nutritional or otherwise, have not been scientifically confirmed. Certain persons considered experts may disagree with one or more of their concepts or recommendations. We are not licensed dieticians, but rather consider ourselves to be metabolic bio advisors. Our purposes are for education and information only and we assume no responsibility for the correct or incorrect use of our information. Any information we provide and any recommendations we make should not be used to, nor are they intended to, nor do they in fact diagnose, treat, cure or mitigate any specific health problem. Anyone with any health complaint should seek the care and consultation of an appropriate licensed health practitioner.
"I, the undersigned, do hereby state that I have read the above statement and understand that the purpose of the HealthSmart Nutrition Metabolic Bio Program is solely to provide information concerning my individual ecological lifestyle. I further understand that any recommendations made are in no way intended to, nor do they in fact diagnose, cure, treat, mitigate or prevent any specific illness or disease."

To sign your name electronically, enter a " / " at the start and the end of your name.
Example: /John Doe/

"By electronically signing my name in the box below, I am indicating my acceptance of the content of the Informed Consent statement above ."


Please check and make sure you used a " / " at the start and the end of your name. Without it, your form will be considered unsigned and will not be accepted. Thank you.

Now you're ready to start the questionnaire!

Metabolic Bio Evaluation
For tips on Viewing and Navigating this evaluation click here.

Evaluation Instructions:

  • In the questionnaire below, make only one selection per category (except where otherwise indicated).
  • If no choice applies to you, leave that category unchecked.
  • Answer all questions (except for Diagnosed Health Conditions at the end) the way you are NOW , not the way you used to be, or think you should be, or how you were before getting sick.
  • Important: The choices as written may not describe you exactly. So, it is very important that you choose the answer that best describes your tendencies. The answer does not need to be a perfect description, just an indication of your trend or tendency.
  • It is strongly recommended that you let a close friend or family member check your answers for accuracy, especially the questions in the Psychological Traits section.
  • Be as honest and accurate as you can. After all, you want to be sure to obtain the right information about your Metabolic Bio Type.
  • If you can't decide on an answer, leave the question blank. Do NOT choose the "middle" or average response just because you are uncertain of your answer.
  • When finished, click the "Submit For Evaluation" button at the bottom to email your answers to the HealthSmart Nutrition Processing Centre.
  • Be sure to make a backup copy of your form by following the instructions exactly at the end of the form.
Physical Traits
Female Only

If possible stand in front of a mirror, wearing either a bathing suit or underwear, or nothing you need to be able to see the outline of your body very clearly.

First, compare your body with the drawings. Depending on your weight, you can use either heavier or lighter version of each set. Which one do you most resemble?

A. B. C. D.
2. Question 2 has three versions. Use the one that best fits your weight.
2-1. Use if you are within 20 pounds over or under your best weight.
You are significantly smaller above the waist than below. Lower body is in fairly good shape, but still appears more substantial and stronger than your upper body.
You appear strong and sturdy, with strength deriving from strong bones and/or from muscle. More substantial above the waist than below.
You are fine-boned and graceful, with a good balance of weight and strength above and below the waist.
You are somewhat childlike and undeveloped in appearance, more like a young girl than like a woman.
2-2. Use if you are 20-50 pounds overweight.
You are definitely disproportionate above and below the waist. Stomach is relatively flat, but your rear end and outer thighs carry extra weight.
You appear square and sturdy. Weight is visible on the front of your body and above the waist, especially in your stomach and upper back. Face, hands and feet show extra pounds.
You are curvy, with weight both above and below the waist, but with a defined waist. Face, hands and feet are fairly slim.
You are pudgy all over, like a child who has put on weight.
2-3. Use if more than 50 pounds overweight.
You are disproportionate above and below the waist, with a very substantial rear end. Weight in stomach, but less than the weight on your rear.
You have a prominent stomach, with substantial weight on your back. Rear end has weight, but less than the weight in front.
You are curvy, with extra weight above and below the waist, but still maintain a waist. Your face, extremities (hands and feet), calves and lower arms have put on weight, but less than the weight you have around your middle (chest to thighs).
You have a childlike shape, underdeveloped look with fat (often like baby fat) accumulating all over, not in special areas. Pudgy. Undefined outline with little curve at waist. Notable weight accumulation in knees, hands and feet.
Build (check all that apply)
Slim, tall/ short, weight changeable, wiry, thin and small-boned
Medium, average athletic tendency, average muscle definition, soft, slight belly
Sturdy, solid, muscular may put on weight, thick, ample or stocky . Larger bone-structure. stout, prone to obesity
Stocky, chunky
Put a check for each of these statements that are true
When I gain weight I gain it all over my body
Most of the time I can hide my weight in my clothes, but I wouldn't consider being seen in a swimsuit
Obesity runs in my family (many close members of my family are 50 pounds or more overweight)
If all the fat on my body disappeared I think I would look great
If all the fat on my body disappeared I think I might be skinny or bony
I tend to gain weight in specific areas (belly, "love handles", thighs, etc,) while much of the rest of my body stays "normal"
I believe that I am genetically doomed to be "fat" and will always be "fat"
If I flex my arm I can feel a muscle
More than being overweight, my problem is that my body lacks shape or definition
I have only had trouble with my weight for the last three to five years
If I had to pick a shape to describe my body it would probably be "round"
Chest Size
Thin flat chests
Very enlarged round
Weight Loss (check all that apply)
Even though I may choose to lose weight or not, I would like to increase the size of some of my muscles to give my body more shape and definition
Even though I may have more fat than I want, my body underneath is still pretty "solid" (hard or firm underneath when I flex my muscle)
Even if I lost all the fat I wanted, I'd never be skinny. I have more meat on my bones than that
Front View
Viewing yourself from the front, which of the following best describes your basic shape?
Disproportionate between upper and lower body : small head, shoulders, breast and chest, long waist, heavier lower body and strong legs
Square, sturdy and strong-looking both above and below the waist. Full-figured, without much of a curve at the waist
Fine-boned and with arms and legs appearing long in proportion to the torso. A pronounced waist and equal curves above and below the waist
Rather childish-looking, without many curves anywhere
Side View
Viewing yourself from the side, which best describes your shape?
Back is slightly swayed, rear end prominent
Back straight, with rear end either quite flat and tucked under, or having a low, flat appearance
Lower back straight, neck coming forward somewhat, rear end rounded but not extremely pronounced
Shoulders quite rounded, head coming forward from the line of the back, rear end small and childlike.
Looking at yourself from the back, where is most of your extra weight?
Quite low on your body : lower hips, outer thighs
High on your body : across the shoulders and back
In the middle of your body : spare tire, wide hips, heavy upper thighs
All over, no single location. Looking at yourself from the side, where are most of your extra pounds?
Back View
Viewing yourself as best you can from the back, which best describes your shape?
Narrow at the shoulders and through the back, greatest width below waist is low (lower hips to upper thighs)
Square-looking from shoulders to hips, shoulders not extremely broad but strong-looking, not much waist curve
About as wide at shoulders and hips, waist curves inward, greatest width below waist is high (upper hips)
Childlike curves, not much waist or hips
Long neck
When overweight short neck
Bony neck, lean throat
Average size for neck
Your hands are:
Longer in palms than fingers, fingers blunt on ends
Square palms, blunt fingers
Long, tapering fingers
Small, delicate, tapering fingers.
Do/did you tend to have cramps during your menstrual period?
First day only
Don't know, never noticed
Your chest and breasts are:
Small chest, small breasts
Large chest, large breasts
Small chest, medium to large breasts
Medium chest, small breasts
Usually under, but when goes up usually in the lower part of the body such as the hips and legs
Maintain normal weight
Weight gain, usually around the waist and in the upper body such as the chest
Looking at yourself from the side, where are most of your extra pounds?
In the back, in a prominent, shelf-like rear end
In the front, in a prominent stomach
Both front and back, with your waist remaining distinct
In a rounded, childlike stomach and rounded rear end, with waist indistinct.
Body Temperature
Very cold
Moderately cold
Weight Gain
Up & down, not easily put on
Tends to stay the same
Usually over
Muscle Tone
Neither narrow or broad
Muscle Size
Little bulk, small, good definition, firm
Average look, neither thin nor bulky, average definition and firmness
Large, bulky look
Skin Sensitivity
Sensitive to touch
Average reaction to touch
Very insensitive to touch
Your face is:
Small for body size, and may have downward-slanting eyes
Square or round
Long, slender
Large for body size
Fat-Thin Areas (check all that apply)
I think parts of my body are too muscular (my buns, my thighs or my arms)
I think parts of my body are too thin (i,e. skinny arms, thighs or calves)
There are parts of my body that are NOT overweight
Ideal Body
To get my "ideal body" I will have to lose: 1 to 2 dress sizes (i.e. from size 8 to size 6 or 4)
To get my "ideal body" I will have to lose: 3 to 4 dress sizes (i.e. from size 14 to size 8 or 6)
To get my "ideal body" I will have to lose: 5 or more dress sizes (i.e. from size 18 to sige 8 or 6)
Weight Issues (check all that apply)
I worry that I am so overweight it is jeopardizing my health
I have had a serious weight problem for nearly my entire life
I need to lose weight ALL over my body
Body Changes (check all that apply)
It is only as I got older that I started to have trouble with my weight
As far as I can remember I have never been so thin that people would call me "bony" or "skinny"
At some point in my life (not counting when I was a little kid), people have said to me: "You should gain weight, you look too thin"
I used to be very athletic, but I don't even recognize my body anymore
Appearance / Look
Wide-awake look and/or eyes protrude
Average look to the eyes
Dreamy look and/or eyes appear deep-set
Puffiness Around Eyes
Tend to have
Occasionally have
Rarely or never have
Eyes, Small appearing, active, dark
Eyes, Medium appearing, penetrating, light sensitive
Eyes, Large appearing, round with thick eyelashes
Pupil Size ( in full spectrum lighted room )
Pupil = black, centre portion of eye. Iris = coloured portion, encircling pupil
Larger than diameter of iris
About the same size as diameter iris
Smaller than diameter of iris
Go long time without blinking or often stare
Average blinking activity
Often blink
Wide open look
Average look
Droopy or saggy, swollen or puffy
Itching Eyes ( not from allergy or candida )
Eyes are rarely itching, even if there is cold or allergy
Occasionally get
Eyes are often itching, even though there isn't cold or allergy
Eyestrain, rarely causes headaches
Eyestrain, Occasional headaches from
Eyestrain causes headaches, sometimes nausea
Eye Vision
Hard to focus
Easy to focus
Average thickness
Thin and scanty
Eyes tend to be dry
Eyes not particularly dry or moist, don't notice
Eyes, often moist and/or watery
Gum Bleeding ( from brushing teeth )
Often occurs
Sometimes occurs
Rarely occurs, if ever
Often hard to swallow, throat seems to tighten up
Sometimes hard to swallow
Rarely or never hard to swallow Teeth Sensitivity ( to hot, cold or acids )
Gum Colour
Dark pink or bluish colour
Medium pink colour
Very pale or light pink colour
Teeth Sensitivity ( to hot, cold or acids )
Teeth often sensitive
Teeth occasionally sensitive
Teeth rarely or never sensitive
Saliva Amount
Excessive amount and/or drooling
Neither Thick nor thin
Dry mouth-eyes-nose, Thick and ropey saliva
Coated, fuzzy, furry
Coating on tongue sometimes
Coated tongue, very rare
Thin, dry, chap easily
Soft, medium-sized
Large, smooth, full
Neither dry or overly moist
Usually quite moist
Frequently hoarse
Bad Breath
Fast, weak, hoarse
Sharp, cutting
Slow, monotonous
Sometimes have
Tend to have
Rarely or never have
Sensitivity to shots, vaccinations- often
Hair Thickness
Coarse and dry
Fine, oily, may have balding or premature greying
Shiny, lustrous, thick
Itching Skin ( anywhere )
Often have
Occasionally have
Rarely have Skin
Ear Colouring ( compared to face and neck )
Flushed, pink, red
Light, pale
Tends to be dry, chaps easily, rough, cool, may have prominent veins
Oily skin, warm, sensitive skin, reddish, inflamed
Cool, thick
Facial Complexion
Rosy, ruddy, bright, clear
Pale, more of a dull, pasty look
Skin tends to be dry, thick, tough
Average skin quality
Skin tends to be thin, weak, delicate
Face usually pale, never flush
Average colouring on face, sometimes flush
Faces flush easily
Had/have often
Occasionally have
Never had
Dry skin
Neither noticeably dry or oily
Oily skin
Neither dry or oily
Tend to be thin, weak, bend easily
Normal texture - not too rough and not too soft
Strong and thick may have severe cross ridges
Fever Blisters/Cold Sores
Never have
May have only once in a while
Usually get when have fever
Gooseflesh or Goosebumps
Easy to form, often form
Occasionally form
Rarely form, if ever
Rarely or never have
Not often, occasional
Often get hives or rashes
Body Odour
Hardly ever, even if doing very hard physical work
Temperature, Extremities cold and/or clammy, cold from tension, Feel chilled often
Feel chilled occasionally
Not easily chilled
Brittle, ridged or cracked nails
Soft and flexible, don't break easily
Strong and thick
Cold sweats often, from palms when nervous
Sweat, sometimes do, occasionally
Perspire easily when hot
Soles of Feet
Soft and no calluses
Average for dryness possibly some calluses
Dry and callused
Body Temperature
Rises easily
Insect Bite/Poison Plant Reaction
Skin reaction, bites, poison ivy or oak, weak reaction or never
Strong reaction, swelling, pain, long time to go away
Average to insect stings or bites or poison plants
Bowel Movements - Colour
Often dark in colour, typically dark brown or green
Light colour feces, perhaps green or yellow colour - liver and gallbladder imbalances
Average brown may appear pale
Urine - Control (check all that apply)
Can hold easily and for a long period
Have trouble stopping flow without dribbling
Difficulty in holding urine, hard to
Don't have trouble stopping flow without dribbling
Bowel Movements - Quality
Irregular Stools tend to be hard and difficult to eliminate without straining (rabbit terds). Frequency variable - tendency toward constipation
Easy and regular, soft, oily and loose, Regular 2-3 per day and tend to be soft or loose (diarrhoea) and quite frequent with strong odour
Large full bowel movement, once a day/mucous, itching, heavy, bulky. Stools may appear pale may have tendency towards constipation
Urine (check all that apply)
Scant, concentrated
Scant, often dark in colour
Profuse, burning
Profuse, milky, cold
Sometimes profuse
Bowel Movements - Frequency of Natural Movement (check all that apply)
Bowels move well
Usually have 1- 2 or more each day, easy to start
Usually have 1 B.M. every other day
Usually have 1 B.M. every 2-3 days or longer, dry, often need enemas or laxatives in order to evacuate bowel
Bowels move sluggish, may have tendency towards constipation
Urine - Frequency ( daytime )
Urination, frequent, sudden urges, more than 5 x per day
Usually 4 x or less per day
3x or less per day
Diarrhoea ( when not ill )(check all that apply)
Tend to get
Often have
Occasionally have
Rarely, if ever, have
Hardly ever get, Usually constipated
Bowel Movements - Size
Usually heavy, large in diameter
Usually average
Hard, dry, small - rabbit terds
Mucous in Stool
Often have mucous in stool
Sometimes have mucous in stool
Rarely, if ever, have mucous in stool
Incontinence ( bowel or bladder )
Often have this problem
Occasionally have this problem
Don't have this problem
Gag Reflex
Tend to gag fast and easily
Average gag reflex
Slow gag reflex
Strong Light
Sensitive to light, irritates, really bothers me. Need to wear sunglasses
Average reaction
Has no effect, doesn't bother at all
Pain Sensitivity
Unusually sensitive to pain, don't tolerate well
Average pain sensitivity
Somewhat insensitive to pain, can handle a lot, very high threshold
Very jumpy and nervous
Occasionally nervous
Very little fear
Neuromuscular Reflexes
Unable to, startles easily, Keyed up; unable to feel calm, Violent reaction to unexpected noise
Usually relaxed but sometimes jump when startled
Can relax very easily
Never have
Occasionally have, or have a mild problem
Often have
Nasal Membranes ( when not ill or allergic )
Tend to be moist or runny
Neither dry nor moist or runny
Often feel too dry
Breathing Rhythm
Tends to be slow, irregular
Sometimes irregular
Almost always rapid & regular
Respiration Rate
More than 20 breaths per minute
Between 13 and 20 breaths per minute
Less than 13 breaths per minute
Chest Pressure ( inhibits breathing )
Rarely or never have
Occasionally have
Often have
Sighing or Yawning ( during day when not tired, not at night )
Usually sigh or yawn every day
Occasionally sigh or yawn
Rarely sigh or yawn
Coughing ( not from allergy or illness )
Often or daily, chronic, frequently, often deep
Hardly ever
Sneezing ( not from allergy or illness )
Sneeze almost every day
Occasionally sneeze
Rarely sneeze
Often have a "sudden gasp for breath" or need to take a big breath or feel like I don't get enough oxygen
Occasionally have a sudden gasp for breath or need to take a big breath or feel like I don't get enough oxygen
Never or almost never have a sudden gasp for breath or need to take a big breath or feel like I don't get enough oxygen
Wheezing ( not from allergy or illness )
Tend to have problems with wheezing
Occasionally wheeze
Rarely or never wheeze
Hay Fever
Have during hay fever season
Only occasionally have during season
Never have during hay fever season
Excess mucous production
Tend to get hoarse often
Occasionally hoarse
Rarely, if ever, hoarse
Rarely get
Sometimes get
Subject to them
I consider my health to be.....
Immune System
Tendency to under -respond, results in infections (sinus, bladder, bowel, skin, etc.)
Average response, occasional infections, colds
Tendency to over-react - results in allergies, sensitivities, autoimmune problems
Catch cold easily
Don't often get colds
Which is your most typical small health problem?
Bladder infections
Sometimes get
Don't often have inflammatory responses
Resistance to Infections
Do you have any of these larger health problems?
Breast lumps
High blood pressure
Chronic allergies
Digestion, Efficiency
Slow, fats and certain proteins especially from meat hard to digest digestive process is generally less efficient
Find fats/oils hard to digest. Fat seems to remain longer in the digestive system - may putrefy
Fast, fats and proteins well digested. Carbohydrates alone may cause problems
Bloating, gas, flatus, burping and abdominal discomfort, usually after large meat meal
Sometimes get
Very rarely
Digestion, Speed
Rapid: stomach empties (clears food) quickly, fast and strong, very good
Average, Handle all foods well
Slow: stomach empties slowly, often food feels like a rock in the stomach especially after eating meats
Thirst Feelings (check all that apply)
Gets thirsty & drinks a lot of water
Gets thirsty easily and often, even if salty foods were not eaten
Occasionally feel thirsty, have average thirst
Rarely feel thirsty
Does not feel thirsty, unless after eating salty foods
Appetite (check all that apply)
Variable, can get very hungry
Low, slight, eats less
Often increased due to carb/sugar response, hypoglycaemic
Often hungry
Diminished or lacking , reduced
Often above normal, always seem to be hungry; 'light-headed' often
After meals, often have
After meals, occasionally
After meals, rarely or never need to burp
Blood Sugar
Tends to be on higher side
Normal - not diabetic or hypoglycaemic
Tends to be on lower side
Stomach Noise
Rumbling or growling of intestines, very little if at all
Rumbling or growling of intestines sometimes
Rumbling or growling of intestines happens a lot
Missing Meals
Irritable and perhaps volatile after missing a meal
Get angry, very irritable, don't do good
Not greatly affected by skipping a meal
Hunger (check all that apply)
Often don't feel hungry, "eat to live"
May feel hungry at mealtimes
Strong, often feel hungry, "live to eat"
Feels weak if doesn't eat every 2-3 hours if eating lots of carbs/sweets/sugars
Don't really get hungry
Varies and can be delicate
Fast, fast metabolism, eats a lot
Rarely or never have
Often get, especially when eating something dry
Nausea (from eating, not the stomach flu or other illness)
Seldom if at all
Sour Stomach
Frequently have
Very rarely
When nauseous, salty food helps
When nauseous, sweet or sour foods help
Stomach Acid (answer only if it has been determined by a Dr.)
Hunger (check all that apply)
If I am even an hour late for a regular meal, I get ravenously hungry
I am rarely hungry at meal times
I get hungry very soon after I eat
I currently only eat once or twice a day
After exercise, I often feel like I am "starving"
Eating Before Bed
Helps me sleep, otherwise wake up hungry during night
Is okay unless I overeat
Usually don't sleep well if I do
Food Reactions (check all that apply)
If I go more than two to three hours without eating I get shaky or irritable
If I go a long time without eating, I get a feeling of "panic"
If I don't eat on schedule, I simply can't control what I eat at the next meal
If I am very tense or anxious, eating a candy bar, bread or pasta tends to calm me down
Weight Gain (check all that apply)
There was a time, after I graduated high school, when I could eat practically anything I wanted and never gain an ounce
It seems like no matter how little I eat, I gain weight
For as long as I can remember, all I had to do was "look at food" and I "would" gain weight
Intestinal Gas 2 Hours After Eating
Often get
Sometimes get
Rarely or never get
Check if applies
Sometimes when I get up too quickly, I get lightheaded or dizzy
I have been off and on diets for much of my adult life
Circulatory System
Blood Pressure (check all that apply)
Normally low - if high - red eyes flushed face
May fluctuates high and low
Most of the time higher than normal
Slow to stop
Normal bleeding time
Short bleeding time, stops quickly
Fast- 80+ per min. - may speed up after meals
Normal - 72-80 per minute
Slow or feels "irregular" (less than 72 beats/min)
Heart Beat
Regular & fast, may pound after retiring to bed
Regular neither fast or slow
In general, I would say that my.....(check all that apply if it is true for you)
Blood pressure is lower than normal
Heart beat is slower than average
Blood pressure is higher than normal
Heart beat is faster than average
Lymph Congestion (indicated by swelling or puffiness)
No swelling anywhere
May occasionally have
Have swelling in legs, ankles, feet etc
Diet-Related Traits
  • It is very important that you answer this section as honestly and accurately as you can.
  • Your answers must reflect your true dietary habits, preferences and reactions.
  • If you don't know or are uncertain of your reactions to certain foods, experiment and test yourself before answering.
  • Do not be in a rush to complete this part of the evaluation.
  • Take your time and consider your responses carefully.
Appetite At Breakfast
Appetite At Lunch
Appetite At Dinner
Love them
Can take them or leave them
Don't care for them
Meal Portion
Like large portions
Normal amounts are just fine - Don't go overboard
Small, don't like much food
Eating Habits
Need to eat often to be at my best
Average eating requirements
Unconcerned with food, may forget to eat
4 Hours Without Eating
Makes me irritable, jittery, weak, or depressed
Feel normal hunger without other ill effects
Doesn't bother me
Likes breakfast, needs it
Doesn't want breakfast
Liquid Fasts
Don't do well, feel awful
May have slight problems but overall - okay
Feel fine, improves health
Acidy Foods
Acid foods upset
Take them or leave them
Prefer, love, enjoy sometimes to the point of craving
Taste Preferences (Choose only one-the closest of the three categories below that fit you)
Sweet : Sugar, honey, cream, rice, wheat, butter, milk, ghee, dates, sweet fruits, coconut and licorice root
Sour : Yogurt, lemon, cheese, bitter melon, Barley, Fenugreek, olives, pickles, tomatoes
Salty : Salt, Kelp, Salty Pickles, Soya Sauce, Anchovies, Sauerkraut
Pungent : Spicy foods, ginger, hot peppers,Cumin, Chilli, black pepper
Bitter : Green leafy vegetables, Turmeric, chocolate, aloe vera, spinach, rhubarb
Astringent : Beans, Lentils, Pomegranate, Apple, Quinoa, Sprouts
Bland: Boiled potatoes, white rice, tofu, crackers and dry toast
Sweet, sour, salty
Sweet, bitter, astringent, bland
Pungent, bitter, spicy, astringent
Food Preferences
Imagine you are at a banquet and could eat anything you wanted with no restrictions what foods would you go for over anything else (check all that apply)
Salty food
Sweet & sour foods
Avocados, love them
Dairy Products
Fatty meats, red meats
Crave Salty food
Well-done roast beef
Grapefruit juice
Avocados, olives, mayonnaise
Onions with meats
Bacon with meats
Easily digestible foods
Food Choice
Could be a vegetarian, love vegetables and fruit
Carnivore or vegetarian, it doesn't matter
Could be a Carnivore, love meat
Which would you consider your main food craving?
Rich and spicy food
Greasy, salty food
Sweets or starches
Dairy products
How much coffee, tea or cola with caffeine do you drink each day?
None or one
One or Two
Three or four
Five or more
Which would you be most likely to succumb to if you find yourself in a fast food restaurant at the end of a long, tiring afternoon?
A taco
A cheeseburger
A sweet roll or cookies
A milk shake
Eating Meat
Makes you sleepy, don't like (not because of how it is processed or what it contains), don't feel good
Okay, no problem
Makes you feel better, fills you up and satisfies
Fatty Foods
Dislike fatty or oily foods (not because of gall bladder problems)
Neither have a preference for nor dislikes
Love, desire fatty foods like cream sauces, cream soups, onion rings, cheese cake etc
Eating Fruit Alone
Energizes and satisfies me, seem to need
Okay, no problem. Doesn't make any difference if I don't have it
Makes me feel jittery or jumpy
Do well with
Can take it or leave it
Bothers me
Could be....
Total Carnivore
Pure Vegetarian
Food Dislikes (check all that apply)
Avocados - too fatty
Grapefruit juice tastes too sour
Coffee causes jitteriness
May have problems with a large meat diet
Mustard tastes & smells too sharp
Large Egg and Bacon Breakfast
Can't take
Can take it or leave it
Prefer it
Psychological Traits
  • Try to answer this section as honestly and accurately as you can.
  • If you don't know or are uncertain of the correct answer to a question, leave it blank. Do not guess or make a selection 'by default.'
  • It can be very helpful to ask a close friend or family member to review your answers in this section. Sometimes we do not see ourselves as others do. Hearing how others perceive us can be very helpful. But remember, no one knows you as well as you do, so what you feel and believe is the most important factor in making your selections.
  • Do not be in a rush. Take your time. Consider your responses carefully.
Tendency toward fear or anxiety when under stress
Tend toward anger, frustration or irritability when under stress
Tendency to avoid situations that are difficult
'Big Heart'
Not really
Often said to have
I feel I am..
Curious, active, creative, fluctuating
Intelligent, irritable
Slow, diplomatic, calm, receptive
Relaxed, calm, firm and positive
My character is....
Nervous, Insecure, non-conformist, fearful, anxious, unpredictable
Argumentative, aggressive, irritable, angry, restless
Conservative, calm, solid, slow, attached, greedy, Compassionate, may tend to attachment
Not at all
My mind is....
Active, restless
Focused and sharp
Calm and slow
Extremely active, hard to slow down
Sluggish, easy to be inactive
Passionate, may tend to anger, resentment
Lay back, friendly
Very good
Not very
Poor, start/stop quickly
Moderate, heat intolerance
Excellent endurance, slow to start
Get angry easily, explode, but passes quickly
Get angry if really pushed
Seldom get, fairly even-tempered
Good short term, long-term is poor
Good long term , short term not as good
Highly emotional
Outwardly appears as very calm, showing no emotions at all, holds in
Enhanced ability to
Normal, average
Poor, hard to
Get Up and Go
Easy to get going in morning
Occasionally hard to get going in morning
Hard to get going in the morning
Not very
Energy Reserve
Usually have lots
Like to make
Average time for making up mind
Desire to be cautious, slow to make
Impatient, irritable
More towards the relaxed attitudes
Not very
"Slow starter", Weak to get things done
A lot of "get up and go" or drive, Strong to get things done
Accomplish tasks but don't go overboard, Average to get things done
Not really
Sometimes have
Emotional Stability
Emotional instability, easily upset
Occasional upsets
Emotionally stable
Mental Quickness
Good, catch on very quick
Average motivation
Not much "get-up-and-go"
Moods, frequent severe changes
Seldom moody, even
Often feel sad or dejected
Nervous Strain
Physical Coordination
Activity Level
Very active, hard to slow down
Have average activity levels, sometimes lethargic
More sedentary, easy to be inactive, lethargic
Physical Quickness
If/when you exercise why do you do it?
Because moving feels good
Because I'm supposed to
So I can eat more later
To get an exercise "high"
Often Lack
Good steady
Which best describes your disposition?
Sensuous, warm and comfortable
Friendly, open and practical
Lively and temperamental
Intellectual, detached,idealistic
If you could have any job in the world, which would you choose?
Teaching something you love
Marketing something you believe in
Creating something you feel passionate about
Designing something people don't even know they need yet
Which best describes your temper?
Quick-tempered but easily distracted by flattery or apologies
Slow to get angry, but when you are, you stay mad for a while
Impatient, inclined to get depressed when thwarted
Get upset after the event, have a hard time communicating about it
When you're "up", you're
Radiant and loving
Friendly and outgoing
Sparkly and funny
Giggly as a happy child
When you're down, you're
Depressed, irritable
Withdrawn, obsessed
Love/do better in warm or hot weather. Usually suffer from cold
Do equally well in warm or cool weather
Love/do better in cool or cold weather. Usually suffer from heat
Stiffness Upon Arising
Muscles often feel stiff upon arising
Occasionally feel stiff upon arising
Rarely feel stiff upon arising
Fever ( when ill )
Tends to be higher
Average fever
Tends to be lower
Medication Response
Quick, maximum side effects, needs low dose
Medium, may have aspirin sensitivity
Slow, needs high dose
Cold, dryness
Sun, heat
Cold, damp
Tissue Repair
Repairing, Rebuilding, Healing, Rejuvenating of Tissue, Slow
Repairing, Rebuilding, Healing, Rejuvenating or tissue normal
Repairing, Rebuilding, Healing, Rejuvenating of tissue, Fast
Physical Endurance
Can work steadily for many hours at a time
Average endurance
Tend to do better working in spurts
Dream Type
Dreams are fearful, flying, movement
Dreams, fiery, angry, violence, passionate
Dreams peaceful, romantic, water, ocean
Sleep Time
Less, 6 or less hours. Light sleeper, Scanty, disturbed
Moderate, 7-8 hours, sound, Usually sleep well
Heavy, prolonged, Long, over 8 hours
Weak, if dream at all, Can't recall
Sometimes dream Varies in intensity
Dream frequently, vivid and often in colour, recall most dreams
Difficulty in falling asleep
Average - Seldom have insomnia
Fall asleep quickly
Physiological Features
Physical Activity
Very physically active
Love exercise, Enjoys physical activity, especially competitive
Very inactive
Enjoy - are "exercise nuts"
Sometimes like
Dislike very much
Hand/Eye Coordination
Team Player
Not really
May or may not be
Very much so
Will to Win
Like to but not bothered if don't
Physical Endurance
Poor - lack of
Moves quick, does things quick
Has little
Not at all
Reaction Time
Miscellaneous (check all that apply)
I have always been "athletic" but recently the pounds have begun to creep on,
I have lots of energy. People are always amazed at how quickly I'm moving through the world,
I have very low energy levels for much of the time
When I get more physical activity in my life, my body loses fat fairly quickly.
Diagnosed Health Conditions
Check all that apply.
Buerger's Disease (clotting , inflam. art. in veins of feet, hands)
Cold sores
Get lots of colds; flu, gripe
Colitis, mucus
Canker sores
Caries (cavities)
Gums, bleeding, receding
Fever Blisters
Headaches (due to reduced blood pressure and reduced circulation in brain)
Healing; bones, slow
Healing; tissues, fast
Heart attacks, several
Herpes zoster (shingles)
Histamine reactions
High temperatures
Infections, viral
Hypertension (High Blood Pressure)
Intermittent claudication
Hypochlorhydria (Low stomach acid)
Jittery feeling
Leukopenia (abnormal decrease in the number of white blood cells)
Kidney stones
Kidney, infections
Phlebitis (inflammation of a vein)
Oxygen metabolism, poor
Postnasal drip
Pellagra (Deficiency in Niacin, Vit B2)
Asthenia (lack of strength or weakness)
Pyorrhoea ( Purulent inflammation of the gums and tooth sockets)
Sex problems
Skin reactions- Warts
Ulcers, duodenal
Veins, varicose
Vincent's infection (gingivitis)
Calcium deposits Spurs
Allergic asthma
Breast Cancer
Arthritis, rheumatoid
Prone to fainting or episodes of dizziness
Heart disease
Rheumatoid arthritis
High blood pressure
Stomach ulcers
Liver problems
Traumatic arthritis
Sensitivity to Nitrates. Nitrites, MSG
Cuts heal slowly
Diabetes mellitus
Chorea (various disorders of nervous system, jerky movement)
Circulation, poor from muscle tension
Dropsy, Edema (pooling of blood feet/legs)
Colitis, ulcerative
Conjunctivitis (pinkeye)
Cystitis (Inflammation of bladder)
Fatigue, chronic
Frequently cough up mucus
Febrile diseases (diseases that have high fevers)
Hay fever
Glossitis (Tongue infection, inflammation)
Headaches; and/or eyestreain, and/or hypoclycemia
Heart attack, massive
Headaches; migraine, tension
Healing; bones, fast
Healing; tissues, slow
Herpes simplex
Angina pectoris
Infections, bacterial
Leg ulcers
Arthritis hypertrophic, osteo
Legs, restless at night
Oxygen metabolism, good
Periodontoclasia (gum disease)
Purpura (Easy bruising Small red dots that show up on skin)
Skin, Eczema
Rheumatic fever
Tinnitus aurium (ringing in ears)
Telangiectasia (elevated dark red blotches on the skin)
Ulcers, gastric
Tingling in extremities (from deposits in vessels)
Arteriosclerosis (hardening of arteries)
Uraemia- A toxic condition resulting from kidney disease in which there is retention in the bloodstream of waste products normally excreted in the urine
Cerebrovascular accidents (Strokes)
Inflammations of the joints
Colon Cancer
Low Thyroid
Duodenal and small intestinal ulcers
Gall stones
Pyloric valve stenosis
Reynauds disease
Spastic diseases of the large and small bowels
Calcium deposits Spurs
Bone breaks
Bones, pain in
Brucellosis (bacterial disease affects various organs body)
Lack of Stamina
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