Health Survey

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Health Assessment Test

Take This Health Assessment Test FOR A FREE 15 MINUTE health educational PHONE CONVERSTAION

The symptoms listed in this questionnaire can help determine how the body functions. It is not a test to determine if you have a disease. For instance if a person gets gas after she eats then it’s possible that she needs more enzymes or she eats too much sugar. It does not determine if you have an ulcer. If a person gets light headed if she does not needs to eat every 2 hours it could mean that her ability to digest fat is slow or that she eats the wrong foods. It is not a test for diabetes. I look for patterns of symptoms and then we can talk about what those types symptoms could mean in any person's body. I talk in terms of what types of herbs, detoxification or pressure points would relate to people with those symptoms, but not you necessarily. This is an education not an examination; do not treat it as such. It is an educational conversation, a tool for you to understand how the body works, so that you can be more informed about the body works and to make better health choices. I may even recommend different books to read or how to gather more information. The things I talk about are based on physiology, Chinese medicine theory and nutritional theory. This is not FDA approved. It is thorough and detailed and you will really learn a lot. If you are looking for a diagnosis, you need to make an appointment either here or with your doctor, depending on your situation. Since this is educational only, I only need a first name, after the form is done you will be sent a way to schedule for the free conversation. If you are having a medical emergency dial 911

Dr Stewart Edrich DC 3968 Cerritos Ave Los Alamitos, CA 90720

562-799-0320

Please List your five major health concerns in order of importance

Section A: Stomach/Digestion Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section B: Liver, Gallbladder Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section C: Intestinal Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Allergic Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: D: Blood Sugar Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: E: Vitamin Deficiency

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: F: Pituitary Hormone Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: G: Pituitary Hormone Fatigue

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: H: Thyroid Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: I: Thyroid Fatigue

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: J: Adrenal Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: K: Adrenal Fatigue

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section: L: Mineral depletion

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Section M: Cardio Vascular Stress

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Female Hormone Stress

Female Only

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year.
Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Male Hormone Stress

Men Only

Directions: Please read each description and click on the number, which best describes the frequency of your symptoms within the past year. Key: 0 = Never , 1 = Mild, 2 = Moderate , 3 = Severe

Personal Information

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