contact us for a detailed assessment document. This document can
be faxed or e-mailed to you.
Tel No to contact: (011) 659-0612 or e-mail:firstname.lastname@example.org
This is an example of what type of questions will be asked in the
Please note that ALL information will remain confidential!
REVIEW OF PERSONAL
HEALTH PROBLEMS AND CONCERNS
A full review of your own clinical history is a critical part in
the correct approach to ascertaining what is wrong with you. Your
present feelings and observations about yourself are every bit as
valuable as any laboratory or physical examination. I would like
to know what you sense about your own body's functions and how your
mind and emotions are working. The Review of Personal Health Problems
and Concerns supplied below can be an important tool for you and
for me as you Advisory Health Professional.
You are creating a diagnostic tool in you own home when you have
time and opportunity to reflect on your discomforts. This will save
you time, discomfort, and money.
Have you suffered with any of the following symptoms, if so indicate
with a Y for Yes and N for No.
Please underline the appropriate symptom.
1. Frequent infections, contraceptive pill, constant skin problems-or
taken antibiotics, or cortisone medications often or for long periods?
2. Feeling of fatigue, being drained of energy, drowsiness -
Or similar symptoms on damp, muggy days in mouldy places such as
3. Feeling of anxiety, irritability, insomnia-or cravings for sugary
foods, breads, alcoholic beverages?
4. Food sensitivities, allergy reactions-or digestion problems,
bloating, heartburn, constipation, bad breath?
5. Feeling "spacey" or "unreal", difficulty
in concentrating, or being bothered by perfumes, chemical fumes,
and tobacco smoke?
6. Poor co-ordination, muscle weakness, or joints painful or swollen?
7. Mood swings, depression, or loss of sexual feelings?
8. Dry mouth or throat, nose congestions or drainage, pressure above
or behind the eyes or ears, or frequent headaches?
9. Pains in the chest, shortness of breath, dizziness, or easy bruising?
10. Tick Bite Fever, Rheumatic Fever, Septicaemia?
11. Frustration at going from doctor to doctor, never getting relief
- or being told that your symptoms are "mental" or "psychological"