INNER FRUITS - Health Evaluation

Name of reference / Health worker
Surname	Name
Title	Sex	Male Female
Date of birth	Address
Telephone nu.	Fax nu. (optional)
Medical aid name	Medical aid nu.
Credit Card nu.	E-mail address
Put money into our bank (optional):
Please note that the cost of the health evaluation is R130

Medical history:
Medicinal / Pharmaceutical products used at present
Vitamin / natural products used at present

Click on the symptoms applicable to your health situation:

	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

RECORD your 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