Health Assessment Form STEP 1. If a concern applies to you, circle all numbers in that row. STEP 2. In each column, total the numbers you have circled. STEP 3. Decide which Body Systems you will focus on, based on your highest scored columns. CONCERNS Digestive Hepatic Intestinal Circulatory Nervous Immune Respiratory Urinary Glandular Structural Illness More Than Twice a Year Body Odor and/or Bad Breath Difficulty Digesting Certain Foods Less Than 3 Servings of Fruits and Veggies Daily Monthly Female Concerns Recent or Frequent Use of Antibiotics Regular Consuption of Alcohol Gum Problems or Redness on Nose Food Allergies Puffiness Under Eyes Smoking Poor Concentration or Menory Heavy Coating on Tongue Belching or Gas After Meals Stressful Lifestyle Skin/Complexion Problems Cravings for Sweets or Junk Food Daily Consumption of Daily Products Feeling Down, Uninterested or Moody Difficulty Getting to Sleep, Lack of Sleep Menopausal Concerns Frequent Urination or Urinary Concerns Age-Related Health Problems Sore or Painful Joints Difficulty Maintaining Ideal Weight Lack of Energy or Endurance Diet High in Meat and Grains Heavy Mucus Production or Feeling Congested Fewer Than Two Bowel Movements Per Day Weak Knees, Ankles or Back Low Sex Drive Brittle or Easily Broken Fingernails Dry, Damaged or Dull Hair Daily Consumption of Fried Foods Frequenty Feeling Fearful or Timid Cold Hands and Feet Muscle Cramps or Spasms Exposure to Air Pollution Daily Daily Consumption of Caffeinated Beverages Shallow or Difficult Breathing Restless Sleep or Waking up Frequently Recurrent Yeast or Fungal Infections Weak Bones, Teeth or Cartilage Feeling Anxious or Worried Feeling Irritable or Easily Angered Don't Exercise Regulary Respiratory Concerns TOTAL POINTS POSSIBLE MY TOTAL POINTS BY BODY SYSTEM
