Stewart Edrich, DC 562-799-0320. 3968 Cerritos Ave. Los Alamitos, CA 90720
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Health Assessment Test

Take This Health Assessment Test FOR A FREE 15 MINUTE PHONE CONSULT

This is a test of common symptoms that can give an indication of possible causes of health conditions. Developed over many years of research, for those people with health issues who are interested in what is causing their problems this can be a very valuable tool.

All information from this test is considered private medical information and is protected under law from unauthorized disclosure. We are prohibited by law from releasing your name, address or phone number to any other organization or person. This test is hosted from a secure server, which is the same level of protection used to make secure financial transactions on the web.

Submit your completed test to the clinic for a computer analysis and phone consultation* with a doctor regarding the cause of your health problems as indicated by this test. The doctor will also be able to give you information on various solutions to the types of issues you may have.

* NOTE: Free phone consultations with a doctor are limited to patients who are in the local Los Angeles and Orange County area.

In our experience, the biggest barrier to a higher quality of life is a lack of knowledge or information regarding the cause of health problems and what could be done about them.

This is an opportunity to obtain this information about your level of health.

PART ONE

Check if any of the following medications you are taking:
Antacids Chemotherapy Hormones Relaxants/Sleeping Pills
Antibiotic/Antifunga Cortisone Anti-Inflammatories Laxatives Recreational Drugs
Specify
Antidepressants Diuretics Lithium
Antidiabetic/Insulin Heart Medications Oral Contraceptive Thyroid
Aspirin/Tylenol High Blood Pressure Radiation Ulcer Medications
Other

Check if you eat, drink, or use:

Alcohol Distilled Water Luncheon Meats Non-Herbal Teas
Candy Fluoridated/Chlorinated Water Margarine Chew Tobacco
Carbonated Beverages Eat at fast food restaurants regularly Refined Sugars Vitamins &Minerals
Cigarettes Fried Foods Milk Products
 Specify
Coffee Refined (White) Flour Products Artificial Sweetner  

Check if you:

Diet often Exercise Less than 3 times weekly Are exposed to chemicals at work
Salt food without tasting Are under excessive stress Are exposed to cigarette smoke

PART TWO

Please List your five major health concerns in order of importance

1.
2.
3.
4.
5.

PART THREE

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 A: Stomach/Digestion Stress
Read More

1. Bad breath, halitosis 0 1 2 3
2. Loss of taste for high protein foods (meat, etc.) 0 1 2 3

3.

 Burning (acid) or nervous stomach,eating relieves 0 1 2 3
4. Gas shortly after eating 0 1 2 3
5. Indigestion 1/2 to 1 hour after eating, may last 3-4 hours 0 1 2 3
6. Difficulty digesting fruits or vegetables; undigested foods found in stools 0 1 2 3
7. Acid or spicy foods upset stomach 0 1 2 3

Section B: Liver, Gallbladder Stress
Read More

8.

Lower bowel gas and or bloating several hours after eating

 0 1 2 3
9. Feet burn 0 1 2 3

10.

 “Whites” of eyes (sclera) yellow 0 1 2 3
11.

Dry skin, itchy feet and /or skin peels on feet

0 1 2 3
12. Brown spots or bronzing of skin 0 1 2 3
13. Bitter metallic taste in mouth 0 1 2 3
14. Blurred vision 0 1 2 3
15. Headache over eyes 0 1 2 3
16. Feel nauseous, queasy or gag easily 0 1 2 3
17. Color of stools light brown or yellow 0 1 2 3
18. Greasy or high fat foods cause distress 0 1 2 3
19. Pain between shoulder blades 0 1 2 3
20. Dark circles under eyes 0 1 2 3
21. “Acid” breath 0 1 2 3
22.

History of gallbladder attacks or gallstones Or gallbladder removed

Yes No
23. Appetite reduced 0 1 2 3

Section C: Intestinal Stress
Read More

24.

Coated tongue or “fuzzy” debris on tongue

0 1 2 3
25. Pass large amounts of foul smelling gas 0 1 2 3

26.

Irritable bowel or mucous colitis

0 1 2 3

27.

Constipation, diarrhea alternating or stools alternate from soft to watery

0 1 2 3
28.

Bowel movements painful or difficult, constipation, and/or laxatives used

0 1 2 3
29. Burning or itching anus 0 1 2 3

Allergic Stress

30. Head congestion/sinus fullness 0 1 2 3
31. Sneezing attacks 0 1 2 3

32.

 Dreaming, nightmare-like bad dreams 0 1 2 3
33

Milk products and/or wheat products cause distress

0 1 2 3
34. Eyes and nose watery 0 1 2 3
35.

Eyes swollen or puffy

0 1 2 3
36. Pulse speeds after meals and/or heart pounds after retiring 0 1 2 3


Section: D: Blood Sugar Stress
Read More
37.

Crave sweets or coffee in afternoon or mid-morning

0 1 2 3
38.

Hungry between meals or excessive appetite

0 1 2 3

39.

 Overeating sweets upsets 0 1 2 3
40.

Eat when nervous

0 1 2 3
41. Irritable before meals 0 1 2 3
42.

Get “shaky” or light-headed if meals delays

0 1 2 3
43. Fatigue, eating relieves 0 1 2 3
44.

Heart palpitates if meals missed or delayed

0 1 2 3
45.

Awaken a few hours after sleep, hard to get back to sleep

0 1 2 3

Section: E: Vitamin Deficiency
Read More

46.

Muscle soreness after moderate exercise

0 1 2 3
47.

Vulnerability to insect bites (especially fleas and mosquitoes)

0 1 2 3

48.

Loss of muscle tone or “heaviness” in arms or legs

0 1 2 3
49.

Enlarged heart and/or heart failure

0 1 2 3
50. Worried, feel insecure and/or highly emotional 0 1 2 3
51.

Pulse slow/below 65 or irregular pulse

 Yes No

Section: F: Pituitary Hormone Stress
Read More

52.

Sex drive increased

0 1 2 3
53.

“Splitting” type headaches

0 1 2 3

54.

Memory failing

0 1 2 3
55.

Tolerance for sugar reduced

0 1 2 3

Section: G: Pituitary Hormone Fatigue
Read More

56.

Sex drive reduced or absent

0 1 2 3
57.

Abnormal thirst

0 1 2 3

58.

Weight gain around hips or waist

0 1 2 3
59.

Tendency to ulcers or colitis

0 1