HealthSmart Nutrition's
Program 1 (Male)
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.

STEP 1

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.)
STEP 2

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:

ID NUMBER, LAST NAME, FIRST NAME, EMAIL, HOME PHONE, AGE, HEIGHT (feet and inches), WEIGHT, TEST NUMBER, ADVISOR, ADVISOR EMAIL, ADVISOR CERT #, SIGNATURE (in Step 3).

Date: eg, June 1, 2000
ID Number:
Last Name:
First Name:
Street:
City:
State/Province:
Postal Code/Zip:
Country:
Email:
* NOTE: Please provide complete phone/fax numbers, including country code, area code
Example: 1-243-532-6472
Day Phone: *
Night Phone: *
Fax: *
( 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:
 
Occupation:
Please indicate below the reason for your interest in this program:
Sex:
Body Fat % *
BMI *
* 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
Age:
Birthdate: eg, May 18, 1975
Height: feet'  inches
Weight:
Ideal Weight:
Marital Status: (S)ingle,(M)arried,(D)ivorced
This is my: (1,2,3 etc.) test.
Blood Type:
Advisor:
Advisor Email:
Advisor Phone:
Advisor Fax:
Advisor Cert #:
* NOTE: Please provide complete phone/fax numbers, including country code, area code
Example:1-243-532-6472
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.
Diastolic(mmHg)
Systolic (mmHg)
Pulse:
STOP!

Make sure that the following fields contain data in the table above. Otherwise, when you submit your form, it will NOT go
through! ID NUMBER, LAST NAME, FIRST NAME, EMAIL, PHONE NUMBER, AGE, HEIGHT (feet and inches), WEIGHT, TEST NUMBER, ADVISOR, ADVISOR EMAIL, ADVISOR CERT #, SIGNATURE

STEP 3
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 ."

Signature:

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!

STEP 4
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
BODY STRUCTURE
Male 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.
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 strong and sturdy, with a basically muscular appearance even if you are out of shape. Large chest, sturdy limbs.
You are longer boned, with a more streamlined appearance. Longer limbs, longer face, narrower chest and hips.
You are boyish, more like a young boy than like a man.
2-2. Use if you are 20-50 pounds overweight.
You are square, sturdy and heavy-looking. Weight has accumulated on the front of your body in a pot belly.
You are saggy, out-of-shape looking, with weight all around your middle. Face, hands and feet still relatively slim.
You are pudgy all over, like a child who has put on weight.
2-3. Use if more than 50 pounds overweight.
You have a very prominent stomach, with substantial weight also on your back. Rear end is round and weight extends down legs to feet.
You have extra weight all around your middle, in a large spare tire. There is also a pot belly but it is not confined mainly to the front - it extends all around the middle. Your face, calves and lower arms have put on weight, but less than the weight you carry around your middle (chest to thighs).
You look undefined in outline, with fat all over the body.
 
Back View
Viewing yourself as best you can from the back, which best describes your shape?
Square-looking from shoulders to hips, shoulders not extremely broad but strong-looking, not much waist curve
Wider at shoulders than hips
Narrow shoulders and hips
 
Your face is:
Square or round
Long, slender
Large for body size
 
Skin Sensitivity
Sensitive to touch
Average reaction to touch
Very insensitive to touch
 
Neck
When overweight short neck
Bony neck, lean throat
Average size for neck
 
Front View
Viewing yourself from the front, which of the following best describes your basic shape?
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
Childish-looking, without much definition anywhere
 
Your hands are:
Square palms, blunt fingers
Long, tapering fingers
Small, delicate, tapering fingers
 
Weight
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 back, where is most of your extra weight?
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
 
Body Temperature
Very cold
Warm/hot
Moderately cold
 
Looking at yourself from the side, where are most of your extra pounds?
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
 
Muscle Tone
Good
Average
Poor
 
Weight Gain
Up & down, not easily put on
Tends to stay the same
Usually over
 
Muscle Size
Little bulk, small, good definition, firm
Average look, neither thin nor bulky, average definition and firmness
Large, bulky look
 
Shoulders
Narrow
Neither narrow or broad
Broad
 
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".
 
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
Lean
Average
Stocky, chunky
 
Features
Prominent
Average
Fine
 
Hips
Wide
Average
Narrow
 
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
 
Side View
Viewing yourself from the side, which best describes your shape?
Back slightly swayed, rounded rear end
Lower back straight, neck coming forward somewhat, rear end flat or slightly rounded
Shoulders quite rounded, head coming forward from the line of the back, rear end small and childlike
Ideal Body
To get my "ideal body" I will have to lose: 2-4 inches on my waist
To get my "ideal body" I will have to lose: 4-8 inches on my waist
To get my "ideal body" I will have to lose: 8 or more inches on my waist
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
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
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
Chest Size
Thin flat chests
Average
Very enlarged round
EYES
 
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
 
Description
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
About the same size as diameter fo iris
Larger than diameter of iris
Smaller than diameter of iris
 
Blinking
Go long time without blinking or often stare
Average blinking activity
Often blink
 
Eyebrows
Thick
Average thickness
Thin and scanty
 
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
 
Eyelids
Wide open look
Average look
Droopy or saggy, swollen or puffy
 
Eye Vision
Hard to focus
Average
Easy to focus
 
Eyestrain
Eyestrain, rarely causes headaches
Eyestrain, Occasional headaches from
Eyestrain causes headaches, sometimes nausea
 
Moisture
Eyes tend to be dry
Eyes not particularly dry or moist, don't notice
Eyes, often moist and/or watery
MOUTH
 
Gum Bleeding ( from brushing teeth )
Often occurs
Sometimes occurs
Rarely occurs, if ever
 
Swallowing
Often hard to swallow, throat seems to tighten up
Sometimes hard to swallow
Rarely or never hard to swallow
 
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 Lips
 
Tongue
Coated, fuzzy, furry
Coating on tongue sometimes
Coated tongue, very rare
 
Lips
Thin,dry, chap easily
Soft, medium-sized
Large, smooth, full
 
Mouth
Dry
Neither dry or overly moist
Usually quite moist
 
Other
Frequently hoarse
Bad Breath
 
Voice
Fast, weak, hoarse
Sharp, cutting
Slow, monotonous
 
Your Teeth are:
Large, slightly yellowish, strong (few cavities)
Small, white, weak (prone to cavities)
Large, especially front centre
SKIN
 
Dandruff
Sometimes have
Tend to have
Rarely or never have
 
Shots/Vaccinations
Sensitivity to shots, vaccinations- often
Occasionally
Never
 
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
 
Ear Colouring ( compared to face and neck )
Flushed, pink, red
Average
Light, pale
 
Skin
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
Average
Pale, more of a dull, pasty look
 
Toughness
Skin tends to be dry, thick, tough
Average skin quality
Skin tends to be thin, weak, delicate
 
Flushing
Face usually pale, never flush
Average colouring on face, sometimes flush
Faces flush easily
 
Acne
Had/have often
Occasionally have
Never had
 
Face
Dry skin
Neither noticeably dry or oily
Oily skin
 
Hair
Dry
Neither dry or oily
Oily Fever
 
Fingernails
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
 
Hives/Rashes
Rarely or never have
Not often, occasional
Often get hives or rashes
 
Body Odour
Hardly ever, even if doing very hard physical work
Profuse
Moderate
 
Chills
Temperature, Extremities cold and/or clammy, cold from tension, Feel chilled often
Feel chilled occasionally
Not easily chilled
 
Nails
Brittle, ridged or cracked nails
Soft and flexible, don't break easily
Strong and thick
 
Sweating
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
Normal
Low
 
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
ELIMINATION
 
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
 
Gas (check all that apply)
Intestinal Gas, often sweet odour
Intestinal Gas, foul odour
Intestinal gas, often get
 
Mucous in Stool
Often have mucous in stool
Sometimes have mucous in stool
Rarely, if ever, have mucous in stool
 
Bowel Movements - Size
Usually heavy, large in diameter
Usually average
Hard, dry, small - rabbit terds
 
Incontinence ( bowel or bladder )
Often have this problem
Occasionally have this problem
Don't have this problem
REFLEXES
 
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
 
Fear
Very jumpy and nervous
Occasionally nervous
Very little fear
 
Neuromuscular Reflexes
Fast
Average
Slow
 
Relax
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
RESPIRATION
 
Asthma
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
Occasionally
Hardly ever
 
Sneezing ( not from allergy or illness )
Sneeze almost every day
Occasionally sneeze
Rarely sneeze
 
Gasping
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
 
Health
Excess mucous production
 
Hoarseness
Tend to get hoarse often
Occasionally hoarse
Rarely, if ever, hoarse
IMMUNOLOGICAL
 
Colds/Asthma/Bronchitis
Rarely get
Sometimes get
Subject to them
 
I consider my health to be.....
Poor
Average
Good
 
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
 
Colds
Catch cold easily
Don't often get colds
 
Which is your most typical small health problem?
Constipation
Fatigue
Colds
 
Inflammation
Increased
Sometimes get
Don't often have inflammatory responses
 
Resistance to Infections
Poor
Moderate
Good
 
Do you have any of these larger health problems?
High blood pressure
Ulcers or colitis
Chronic allergies
DIGESTION
 
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
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
Strong
Low, slight, eats less
Often increased due to carb/sugar response, hypoglycaemic
Often hungry
Diminished or lacking , reduced
Normal
Often above normal, always seem to be hungry; 'light-headed' often
 
Burping/Belching
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
 
Digestion
Varies and can be delicate
Fast, fast metabolism, eats a lot
Slow
 
Hiccoughs
Rarely or never have
Occasional
Often get, especially when eating something dry
 
Nausea (from eating, not the stomach flu or other illness)
Seldom if at all
Occasional
Frequently
 
Sour Stomach
Frequently have
Sometimes
Very rarely
 
Other
When nauseous, salty food helps
When nauseous, sweet or sour foods help
 
Stomach Acid (answer only if it has been determined by a Dr.)
High
Low
 
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
High
Normal
Low
 
Bleeding
Slow to stop
Normal bleeding time
Short bleeding time, stops quickly
 
Pulse
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
Slower
 
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
Weak
Average
Strong
 
Appetite At Lunch
Weak
Average
Strong
 
Appetite At Dinner
Weak
Average
Strong
 
Desserts
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
 
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
 
Breakfast
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)
Fruits
Salty food
Bread
Sweet & sour foods
Sweets
Avocados, love them
Butter
Dairy Products
Fatty meats, red meats
Crave Salty food
Candy
Well-done roast beef
Sugar
Grapefruit juice
Coffee
Mustard
Avocados, olives, mayonnaise
Onions with meats
Potatoes
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?
Greasy, salty food
Sweets or starches
Dairy products
 
How much coffee, tea or cola with caffeine do you drink each day?
None or one
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 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
 
Coffee
Do well with
Can take it or leave it
Bothers me
 
Could be....
Total Carnivore
Pure Vegetarian
 
Food Dislikes (check all that apply)
Meats
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.
 
Trends
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
Sometimes
Often said to have
 
I feel I am..
Curious, active, creative, fluctuating
Intelligent, irritable
Slow, diplomatic, calm, receptive
 
Actions
Relaxed, calm, firm and positive
Explosive
Average
 
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
 
Aggressiveness
Very
Normal
Not at all
 
My mind is....
Active, restless
Focused and sharp
Calm and slow
 
Activity
Extremely active, hard to slow down
Average
Sluggish, easy to be inactive
 
Temperament
Passionate, may tend to anger, resentment
Nervous
Lay back, friendly
 
Agility
Very good
Average
Not very
 
Stamina
Poor, start/stop quickly
Moderate, heat intolerance
Excellent endurance, slow to start
 
Anger
Get angry easily, explode, but passes quickly
Get angry if really pushed
Seldom get, fairly even-tempered
 
Memory
Good short term, long-term is poor
Excellent
Good long term , short term not as good
 
Emotion
Highly emotional
Average
Outwardly appears as very calm, showing no emotions at all, holds in
 
Concentration
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
 
Creative
Not very
Sometimes
Very
 
Energy Reserve
Low
Average
Usually have lots
 
Decisions
Like to make
Average time for making up mind
Desire to be cautious, slow to make
 
Patience
Impatient, irritable
Average
Very
 
Disciplined
Very
Somewhat
More towards the relaxed attitudes
 
Instinctive
Not very
Sometimes
Very
 
Drive
"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
 
Intuition
Not really
Sometimes have
Strong
 
Emotional Stability
Emotional instability, easily upset
Occasional upsets
Emotionally stable
 
Mental Quickness
Good, catch on very quick
Average
Poor
 
Motivated
Very
Average motivation
Not much "get-up-and-go"
 
Moods
Moods, frequent severe changes
Seldom moody, even
Often feel sad or dejected
 
Nervous Strain
Often
Occasionally
Never
 
Physical Coordination
Good
Average
Poor
 
Achiever
Over
Under
Average
 
Activity Level
Very active, hard to slow down
Have average activity levels, sometimes lethargic
More sedentary, easy to be inactive, lethargic
 
Physical Quickness
Good
Average
poor
 
If/when you exercise why do you do it?
Because I'm supposed to
So I can eat more later
To get an exercise "high"
 
Stamina/Endurance
Often Lack
Normal
Good steady
 
Which best describes your disposition?
Friendly, open and practical
Lively and temperamental
Intellectual, detached,idealistic
 
If you could have any job in the world, which would you choose?
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?
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
Friendly and outgoing
Sparkly and funny
Happy as an innocent child
 
If you could work in any situation, which would suit you best?
A well-run corporation with room to move up
Out in the world, traveling
In a serene, well-designed office
 
When you're down, you're
Angry
Depressed, irritable
Withdrawn, obsessed
 
Which of these jobs would you choose?
Production type (salesperson, engineer, executive)
Marketing/creative type
Technical type (computer programmer, accountant)
Miscellaneous
 
Climate
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
 
Dislikes
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
Sleep
 
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
 
Dreams
Weak, if dream at all, Can't recall
Sometimes dream Varies in intensity
Dream frequently, vivid and often in colour, recall most dreams
 
Sleep
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
 
Exercise
Enjoy - are "exercise nuts"
Sometimes like
Dislike very much
 
Hand/Eye Coordination
Great
Average
Poor
 
Strength/Power
poor
average
excellent
 
Team Player
Not really
May or may not be
Very much so
 
Will to Win
Strong
Like to but not bothered if don't
Weak
 
Physical Endurance
Poor - lack of
Average
Marked
 
Speed
Moves quick, does things quick
Average
Has little
 
Competitive
Very
Somewhat
Not at all
 
Reaction Time
Fast
Normal
Slow
 
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
 
Strength
If I had to describe myself as either "strong" or "weak", physically, I would tend to say "strong"
If I had to describe myself as either "strong" or "weak" physically, I would tend to say "weak"
Because of my weight, it is very hard for me to do any kind of exercise
Diagnosed Health Conditions
Check all that apply
Acidosis
Buerger's Disease (clotting , inflam. art. in veins of feet, hands)
Cold sores
Bursitis
Get lots of colds; flu, gripe
Cancer
Colitis, mucus
Canker sores
Cramps
Caries (cavities)
Dermatitis
Emphysema
Allergies
Dizziness
Gingivitis
Epilepsy
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)
Heartburn
Histamine reactions
Hemorrhoids
Hoarseness
High temperatures
Hydration
Hyperirritability
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
Lymphoma
Kidney, infections
Melanoma
Numbness
Phlebitis (inflammation of a vein)
Anxiety
Oxygen metabolism, poor
Postnasal drip
Pellagra (Deficiency in Niacin, Vit B2)
Psoriasis
Asthenia (lack of strength or weakness)
Peyronie's Disease (Hardened Fibrous Tissue -Penis)
Pyorrhoea ( Purulent inflammation of the gums and tooth sockets)
Photophobia
Sex problems, impotence
Pneumonia
Skin reactions- Warts
Ulcers, duodenal
Veins, varicose
Atherosclerosis
Vincent's infection (gingivitis)
Calcium deposits Spurs
Allergic asthma
Anaemia
Diabetes
Arthritis, rheumatoid
Osteoporosis
Glaucoma
Blackouts
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
Cataracts
Diabetes mellitus
Chorea (various disorders of nervous system, jerky movement)
Diverticulitis
Circulation, poor from muscle tension
Dropsy, Edema (pooling of blood feet/legs)
Colitis, ulcerative
Drowsiness
Conjunctivitis (pinkeye)
Edema
Cystitis (Inflammation of bladder)
Fatigue, chronic
Dehydration
Frequently cough up mucus
Febrile diseases (diseases that have high fevers)
Hay fever
Glossitis (Tongue infection, inflammation)
Headaches; /or eyestrain, /or hypoglycemia
Goitre
Gout
Halitosis
Heart attack, massive
Anemia
Headaches; migraine, tension
Hepatitis
Healing; bones, fast
Hernia
Healing; tissues, slow
Herpes simplex
Angina pectoris
Infections, bacterial
Leg ulcers
Insomnia
Leukemia
Arthritis hypertrophic, osteo
Ketosis
Legs, restless at night
Obesity
Mastitis
Osteoporosis
Myocarditis
Oxygen metabolism, good
Nephritis
Periodontoclasia (gum disease)
Purpura (Easy bruising Small red dots that show up on skin)
Skin, Eczema
Rheumatic fever
Sleepwalking
Tinnitus aurium (ringing in ears)
Sluggishness
Tonsillitis
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
Gout
Cerebrovascular accidents (Strokes)
Hayfever
Cirrhosis
Inflammations of the joints
Colon Cancer
Low Thyroid
Duodenal and small intestinal ulcers
Osteoarthritis
Gall stones
Pyloric valve stenosis
Reynauds disease
Spastic diseases of the large and small bowels
Earache
Calcium deposits Spurs
Boils
Bone breaks
Bones, pain in
Brucellosis (bacterial disease affects various organs body)
Prostate Cancer
Lack of Stamina
STEP 5
Submitting Your Form
Please review your answers carefully before submitting for evaluation.
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