Home
|
Product Search
|
Site Map
|
Checkout
|
Track Your Order
Supplement Categories
LIFEWAVE
1 - 9
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
R
S
T
U
V
W
X
Y
Z
Consultation
Flower Essences
Nature's Sunshine Supplements
›
Questionnaire
Items Ordered
Name:
Email
Which medications, if any, do you currently take that has restrictions
Symptoms of a Thin Myelin Shealthing
Does noise, people or commotion get on your nerves?
Never
Seldom
Often
Always
Do you have to recheck things?
Never
Seldom
Often
Always
Do you have a hard time remembering your dreams every day (for about 20 min after awakening)?
Never
Seldom
Often
Always
Do you try to avoid large groups of people or noisy places?
Never
Seldom
Often
Always
Do you hear voices or sounds which are not there?
Never
Seldom
Often
Always
Do you have a hard time concentrating when things are going on around you?
Never
Seldom
Often
Always
Do you have invasive thoughts?
Never
Seldom
Often
Always
Do you play the radio, TV, fan or air conditioner (white noise) to help you sleep better or help you fall to sleep?
Never
Seldom
Often
Always
Does sudden noises startle you?
Never
Seldom
Often
Always
Do you have rituals that you need to do to feel you did something right?
Never
Seldom
Often
Always
Do you tend to turn things off or down when someone is talking to you?
Never
Seldom
Often
Always
Have you had the sensation that someone has touched you or is sitting or standing next to you but no one is there?
Never
Seldom
Often
Always
Do you ever think you see someone or something out of the corner of your eye but when you turn your head, nothing is there?
Never
Seldom
Often
Always
Do you forget where you are or what direction a place is that you have gone to often?
Never
Seldom
Often
Always
Do you forget common words or names?
Never
Seldom
Often
Always
Do you have a hard time getting a song out of your head?
Never
Seldom
Often
Always
Do you feel compelled to say your prayers over and over again, fearing you have not said them right?
Never
Seldom
Often
Always
Symptoms of a Weak or Toxic Liver
How often do you have bowel movements?
Never
Seldom
Often
Always
Do you get night sweats?
Never
Seldom
Often
Always
Do the muscles in the shoulder/neck area get tight?
Never
Seldom
Often
Always
Do you feel bloated after you eat?
Never
Seldom
Often
Always
Do you have flatulence (passing gas) more than 1 time a week?
Never
Seldom
Often
Always
Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?
Never
Seldom
Often
Always
Do you have diabetes or feel like taking a nap after you have eaten a large meal?
Never
Seldom
Often
Always
Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?
Never
Seldom
Often
Always
Do you have diabetes or feel like taking a nap after you have eaten a large meal?
Never
Seldom
Often
Always
Do you wake up at night (to urinate or fluff the pillows or look at the clock, etc.) between 1 and 5 and then go back to sleep?
Never
Seldom
Often
Always
Do you have or have you ever had psoriasis, eczema, boils or acne?
Never
Seldom
Often
Always
Do you have or have you ever had moles or skin tags?
Never
Seldom
Often
Always
What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol?
(Please give exact number, if not sure please put "not sure")
What is your total cholesterol number?
(Please give exact number, if not sure please put "not sure")
What is your triglyceride number?
(Please give exact number, if not sure please put "not sure")
Are you on cholesterol medicine?
(Please list all)
Have you ever had hepatitis or cirrhosis of the liver?
(Please list all)
If female, do you have or have you ever had cysts on your ovaries? If male, mark never
Never
Seldom
Often
Always
If female, do you have or have you ever had heavy or clotty, frequent or missed menses (periods or menstruation), or endometriosis? If male, mark never
Never
Seldom
Often
Always
If female, have you had fibroids, tumor in breast or uterus? If male, mark never
Never
Seldom
Often
Always
If female, do you have or have you ever had mood swings, PMS, or menopausal problems? If male, mark never
Never
Seldom
Often
Always
Have you ever had hot flashes?
Never
Seldom
Often
Always
If male, have you ever had a high PSA or swollen prostate (including prostate cancer)? If female, mark never
Never
Seldom
Often
Always
Symptoms of a pH imbalance -- acidosis or alkalosis
Do you happen to know your saliva and urine pH? If so please put here
Do you suffer from sinusitis or have mucus in the head area or nasal drip?
Never
Seldom
Often
Always
Do food or pills feel like they get stuck in your esophagus?
Never
Seldom
Often
Always
Do you have any stiffness or cracking in your joints?
Never
Seldom
Often
Always
Do you experience muscle weakness or soreness?
Never
Seldom
Often
Always
Do you have more than 5 bowel movements a day or diarrhea?
Never
Seldom
Often
Always
Have you experienced a weakness or discomfort in the lower back?
Never
Seldom
Often
Always
Do you get acid reflux or heart burn?
Never
Seldom
Often
Always
Do you have high blood pressure?
Never
Seldom
Often
Always
Do you retain water or have puffiness under your eyes?
Never
Seldom
Often
Always
Do you get charley horses?
Never
Seldom
Often
Always
Do you know if you have any plaque build up in your arteries?
I don't knowr
Some
A lot
Have had bypass or angioplasty
Symptoms of a Glandular Weakness
What is your body temperature ? (Give Exact number in Fahrenheit, do not put normal)
How many moons do you have on the bottom of your fingernail cuticles?
Do you feel as tired when you wake up as you did when you went to sleep?
Never
Seldom
Often
Always
Do you gain weight easily?
Never
Seldom
Often
Always
Do you experience sensitivity to the cold?
Never
Seldom
Often
Always
Do you experience mood swings and/or depression?
Never
Seldom
Often
Always
Have you noticed reduced initiative?
Never
Seldom
Often
Always
Do you have a lower level of stamina?
Never
Seldom
Often
Always
Do you now or have you ever had LOW blood pressure?
Never
Seldom
Often
Always
Does your skin get dark where clothes or skin rubs (for instance around the pant waist band or bra or inner thigh)?
Never
Seldom
Often
Always
Do you have a hard time getting to bed early AND do you have a hard time awakening early in the morning?
Never
Seldom
Often
Always
Do you have an energy dip around 2 to 3 pm and then get your second wind later on?
Never
Seldom
Often
Always
Symptoms of Yeast Overgrowth
Have you taken antibiotics or birth control?
Do you have dry or cracked or rough skin on your feet, heels or hands?
Never
Seldom
Often
Always
Do you have chronic fatigue?
Never
Seldom
Often
Always
Do you feel the urge to urinate frequently OR when your bladder is not full?
Never
Seldom
Often
Always
Do you get jock itch (male) or vaginal yeast infections (female)?
Never
Seldom
Often
Always
Do you get thick toenails or have fungus on your toenails?
Never
Seldom
Often
Always
Symptoms of a Weak Digestion
Do you burp more than 2 times a week? (not including after drinking soda)
Do you have rough skin around your nails or hangnails on hands or feet?
Never
Seldom
Often
Always
Do you have a crease down the middle of your tongue?
Never
Seldom
Often
Always
Do you feel hungry soon after you eat?
Never
Seldom
Often
Always
Do you feel sick after you eat or if you skip a meal?
Never
Seldom
Often
Always
Symptoms of a Vitamin or Mineral Deficiency
Do you crave milk products?
Never
Seldom
Often
Always
Do you crave sweets?
Never
Seldom
Often
Always
Do you crave salty foods?
Never
Seldom
Often
Always
Do you crave potato chips?
Never
Seldom
Often
Always
Do you crave fatty foods?
Never
Seldom
Often
Always
Do you crave alcohol?
Never
Seldom
Often
Always
Do you crave chocolate or coffee?
Never
Seldom
Often
Always
Do you crave ALL foods?
Never
Seldom
Often
Always
Does your heart ever flutter?
Never
Seldom
Often
Always
Do you have lower back pain?
Never
Seldom
Often
Always
Do you get Charley horses (muscle cramps)?
Never
Seldom
Often
Always
Do you retain water?
Never
Seldom
Often
Always
Do you have high blood pressure?
Never
Seldom
Often
Always
Do you have hemangiomas (looks like a little blood mole), varicose veins, or spider veins?
Never
Seldom
Often
Always
Do your gums bleed when you brush your teeth?
Never
Seldom
Often
Always
Do you get cracks or sores in the corner of your mouth?
Never
Seldom
Often
Always
Do you have ridges in your fingernails?
Never
Seldom
Often
Always
Do your eyes get dry?
Never
Seldom
Often
Always
Blood Sugar Balance Symptoms
Are you a diabetic?
No
Controlled by Diet
Insulin
Out of control even with meds and insulin
If you eat a large meal do you feel tired or sluggish?
Never
Seldom
Often
Always
Have you ever been diagnosed with hypoglycemia (low blood sugar)
Never
Seldom
Often
Always
If you skip a meal do you feel ANY of the following? weak, headachy, grouchy, aggressive, or depressed?
Never
Seldom
Often
Always
Symptoms of Circulatory Problem
Have you needed bypass surgery or angio plasty?
Never
Seldom
Often
Always
Do your hands or feet get cold, fall asleep, get numb, or experience the sensation of needles?
Never
Seldom
Often
Always
Do you get out of breath easily?
Never
Seldom
Often
Always
Do you get chest pains or pains radiating down the left arm or up to the left jaw?
Never
Seldom
Often
Always
Have you been diagnosed with any heart conditions?
Never
Seldom
Often
Always
Symptom of Gallbladder Problem
Have you ever been diagnosed as having a gallbladder problem?
Never
Seldom
Often
Always
Have you ever had your gallbladder removed?
Never
Seldom
Often
Always
Does greasy food upset your stomach?
Never
Seldom
Often
Always
Do you ever get a pain under your right rib cage or up between the shoulder blades?
Never
Seldom
Often
Always
Do you fell sick or vomit green/yellowish bitter fluid?
Never
Seldom
Often
Always
Do you usually skip breakfast because your stomach feels queezy or not ready for food inthe mornings?
Never
Seldom
Often
Always
Symptoms of Respiratory Problem
Have you ever been diagnosed with a lung disease?
Never
Seldom
Often
Always
If you have been diagnosed with a lung disease, what is the name of the disease?
Do you consume milk products on a daily basis?
Never
Seldom
Often
Always
Do you smoke?
Never
I use to in the past
I currently smoke
I am trying to quit
Do you get 1 productive (loose mucus cleanse) cold a year?
Never
Seldom
Often
Always
Do you get out of breath easily?
Never
Seldom
Often
Always
Can you inhale for 10 counts, hold for 10 counts and exhale for 12 counts?
Never
Seldom
Often
Always
Emotions Can Effect Health
Do you get angry EASILY?
Never
Seldom
Often
Always
Are you Extremely nurturing?
Never
Seldom
Often
Always
Are you OVERLY impulsive?
Never
Seldom
Often
Always
Do you change your personality to mirror the people you are with?
Never
Seldom
Often
Always
Are you fearful?
Never
Seldom
Often
Always
Do you LACK joy in your life?
Never
Seldom
Often
Always
Do you LACK a close relationship to God (i.e. do you feed the spiritural part of your self sufficiently)?
Never
Seldom
Often
Always
Have you every been diagnosed with a disease or health condition? If so please list all.
Are you on any medication which has diet or supplement restrictions? If so please list.
Are you on a blood thinner or have a bleeding disorder?
Are you on SSRI's?
What is your birth date? MM/YR*
What is your email?
If you have a discount coupon, please enter coupon # here*
How did you hear about us?
Update
Submit
Search by Keyword
Search
Please help us spread the word by bookmarking our site using the button below
Shopping Basket
Items:
0
Subtotal:
$0.00
Note:
All prices in US Dollars
Nature's Sunshine Supplements
·
Product Ordering
·
About Us
·
Contact Us
·
Shipping
·
Privacy Policy
·
Disclaimer
Copyright © 2010 Dr. Mary Reed Gates, CNHP, MH, ND, Lancaster, PA
MarysHerbs
@aol.com
