Health evaluation PDF Print E-mail
Saturday, 16 May 2009 12:47

Fill in the form below, initiate the payment with our reception and you will, within 2-3 days receive an email with a report.

NB*** - BUY more than three PRODUCTS now for 33% discount (not on oil, soap and books).

Cost of a health evaluation:

Telephonic:         R200

Email:                  R200

Personal in-room:  R350                                        

 

Products are now at 33% discount when buying more than three products.

Contact Suret personally for intravenous vitamins prepared per prescription.

Name of reference
Full name   Email
Title   Sex Male Female
Date of birth   Address
Telephone nu.   Fax (optional)
Medical aid name   Medical aid nu.
Credit card nu.      
Put money into our bank (optional)    
Please note: Cost of the health evaluations - Telephonic is R200, by Email is R150 and personal inroom appointments with Suret Morkel is R300.
Medical history:  
Medicinal / Pharmaceutical products used at present  
Vitamin / natural products used at present  
Please click on the symptoms applicable to your health situation lately
1 Acne
2 Addictions: smoke, drugs, alcohol
3 Adrenal exhaustion
4 Age: past the age of 60
5 Ageing prematurely: too fast
6 Ageing: brown spots on skin
7 Allergy: also lactose intolerant
8 Allergy: hay fever/sinus/throat dry/nasal congestion/pressure above eyes/ears
9 Anaemia: iron levels low
10 Anger: unresolved and easily irritated/Aggression
11 Antibiotic usage/more than once in lifetime
12 Anxiety
13 Apathy/listlessness
14 Arteries: arteriosclerosis
15 Arteries: vascular disorder or blockage of arteries
16 Arteries: weak or lesions in arteries
17 Arthritis/rheumatic fever/gout/herberdene's nodes/inflammatory conditions
18 Asthma: bronchial problems
19 Behaviour: compulsive or thought patterns compulsive or behaviour problems
20 Back pain – lower
21 Bladder problems/urination painful
22 Bloatedness/wind/gas
23 Blood : clots easily or had a stroke/heart attack
24 Blood: pressure
25 Blood :sugar regulation: diabetic – sugar regulation problems/high or low/abnormal thirst/temporary pep up from sweet things/tired after eating sweet things
26 Blood: intravenous treatment: had or receiving presently
27 Blood: cholesterol
28 Blood: haemorrhoids
29 Bones: density problem - osteoporosis/bone loss, fragile, break easily, teeth not strong
30 Burning hands and feet (can't wait to remove shoes)
31 Brain damage: did you at any stage in your life had brain damage?
32 Breath: problem/gum disease/bad breath
33 Breath: shortness of breath
34 Breast: sore, PMS or other such as menopausal
35 Cancer (had or have now)
36 Cardiovascular health: not well
37 Cardiovascular: heart - irregular rhythm/racing
38 Chemotherapy or radio therapy – had or receive presently
39 Infections: Chronic infections - viral/bacterial/yeast/parasitic/nasal/bronchial/vaginal/colon etc.
40 Cold hands and feet
41 Colic: baby colic or bowel cramps
42 Colitis or Crohn's disease
43 Colon: stools not formed well
44 Colon: bowel pains (ulcerative colitis)
45 Colon: constipation
46 Concentration: problems, focus, learning disablility
47 Cortisone usage
48 Cramps: legs or elsewhere
49 Dental: mercury fillings, more than 5 dental fillings
50 Dental: toothaches
51 Depression/or manic depression
52 Diet insufficient: not rich in vitamins/minerals – too much carbohydrates
53 Diarree / Loose stools
54 Diet: cravings (sweet things, food, alcohol, sugar coffee, bread, drugs, nicotine, caffein)
55 Diet: poor, suffer from malnutrition
56 Diet: restaurant food/take aways, travel a lot
57 Diet: need a nutritional health drink (for school)
58 Diet: need a well balanced meal replacement – which will aid to loose weight
59 Diet: vegetarian
60 Digestive/gastric problems
61 Digestive: ulcer (duodenum or elsewhere)
62 Diseases: any long term disease?
63 Diseases: tropical disease (Malaria, Bilharzia, etc)
64 Diseases: Auto-immune (Grave's etc)
65 Dizzyness
66 Drinking water - non filtered or polluted
67 Dream recall poor
68 Ear wax – thick or absent
69 Endometriosis or cysts of the female organs
70 Energy: lack of energy/exhausted
71 Enzymes: enzyme production not good enough
72 Epilepsy/twitches
73 Exercise: a lot, physical endurance, or sport
74 Exercise: work out in a gym regularly – do strength exercise
75 Eye sight: night blindedness
76 Eye: problems/poor vision
77 Eyes: cataracts/red/clarity poor
78 Female problems: menopause or hot flushes
79 Fertility: problems
80 Fingers: stiff
81 Gallbladder: problems
82 Growth hormone: would like to have growth hormone/pituitary function improved
83 Growth: stunted/too slow
84 Gums: inflamed, sore/bleed easily/red infected
85 Hair: loss/bad condition/greying
86 Headaches/migraines
87 Healing after surgery
88 Hormonal: imbalance
89 Hyperactivity/ADD/ADHD
90 Hyperexcitable
91 Ice craving
92 Immune system: bad,/weak or problems (such as Aids)
93 Impotence or low sex drive
94 Indigestion, heartburn, ulcers
95 Infections: itchyness/ fungal infections like athlete's foot, jock itch, sinus, finger nails, feet
96 Infections: genital (male-penile or female-vaginal disease/infection)
97 Insecure, low self esteem
98 Intestinal problems
99 Leaky gut
100 Mastitis when breast feeding
101 Memory: dementia
102 Memory: poor/short term memory problem/memory poor
103 Menstruation problems/heavy flow (exclude PMS)
104 Mental performance: would like to improve/loss of reality/confusion
105 Mental: often suggested problems are mental
106 Metabolism: slow, easily gain of weight
107 Moles: growths/flesh coloured
108 Milk production: breast feeding and not having enough milk
109 Moods: emotional and /or moody
110 Mouth: sores/ulcers/cracks/redness at corners/infections
111 Mind spinning
112 Mucous membranes: dry throat, vaginal,nostrils
113 Multi Vitamin: needed by everybody
114 Muscles: weak/tremors
115 Nails: brittle/redged/white spots
116 Neck:/throat tenderness
117 Nerves tense (stiff neck)
118 Nerves: numbness/tingling of hands and feet
119 Neuro system: parkinssons/Alzheimer/any other neurosystem problem
120 Nose:dry nostrils
121 Nose – bleeding
122 Nose – red, inflamed on both sides
123 Odours/perfumes tobacco bothers
124 Organ: bronchial
125 Organs: abnormal development of organs (heart, liver, kidneys)
126 Organs: kidney disease or stones
127 Organs: liver problem
128 Organs: pancreas/spleen problems
129 Organs: thyroid problems
130 Osteoporosis
131 Oxygen: difficulty in breathing, problem with oxygenation of tissues, transport problem-chronic diseased or tired
132 Pains in hands/feet
133 Neurosystem: spacey feelings (autism also) - as if in a cacoon/another world
134 PH: acid too much stomach acid or blood too acid
135 Physical injuries like tendons/ligaments etc.
136 PMS or hormone related stress
137 Pregnancies: multiple (had more than 1 child)
138 Pregnancy: toxaemia?
139 Prostate problems
140 Psychological: schizophrenia
141 Retarded: Down's syndrome or other
142 Senses: smell and taste not good enough
143 Skin problem (eczema, rash, psoriasis etc) or itchy skin
144 Skin: pimples on arms
145 Skin: bruising easily
146 Skin : legs – bluish red and discolouration
147 Skin: wrinkling
148 Skin/Scalp – painful
149 Skin/stretch marks
150 Sleeping problem: difficulty to fall asleep
151 Sleeping problem: wakes up 3 o'clock at night
152 Sore throat, nasal drip, cough
153 Stomach problem/discomfort
154 Stress
155 Stroke or heart attack
156 Swollen ankles, hands, fingers (oedema)
157 taste: metal taste in mouth
158 Sexual discomfort
159 The Pill (birth control) or HRT(hormone replacement) usage
160 Throat dry/nasal congestion/pressure above eyes/ears
161 Tiredness / chronic
162 Tongue cracks:
163 Tongue: white coated, spru (babies)
164 Tongue: tip red, inflamed, raw, sore/ burning/sensitive to hot fluids
165 Toxic built up:
166 Toxicity: heavy metal toxicity or lead poisoning
167 Toxicity: environmental -live near a busy road or other
168 TB (tuberculosis)
169 Tourette's disease or unvoluntary twitches
170 Urine pink after eating beetroot
171 Viral-chronic condition or herpes or Aids or viral lesions
172 Water retension/usage of diuretics (water pills)/thyroid slow
173 Worms-infested
174 Wound healing slow
Please RECORD your eating habits during the course of one week FOOD
Total 1-7 each sample of food eaten in one week:
E.g. Every day a portion of yoghurt = 7 per week.
1. Bread (white/whole)
2. Biscuits/pancake/waffles
3. Chocolate/sweets
4. Chips
5. Pasta
6. Fish
7. Poultry
8. Red meat
   
SWEETENERS
Record the number of units (teaspoon/tablets) used to sweeten food/beverages:
E.g. 3 teaspoons per day 3x7=21 per week.
Honey
Sugar
Artificial sweetener
   
WATER/BEVERAGE
Record the number of units (cups, glasses, tots) taken per week:
E.g. 3 glasses of water every day 3x7=21 per week.
1. Herbal tea/water
2. Coffee
3. Tea
4. Tinned/diluted soft drinks
5. Drinks
6. Milk
7. Fruit juice
   
SMOKE
Do you smoke?    yes no
Does someone in your immediate vicinity smoke?    yes no
   
POLLUTION
Do you live in a polluted area?    yes no
   
Language of preference (for recommendation):    English Afrikaans
   
 

 

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