Body System Questionnaire
www.askmara.com | Mara Gerke CA, CNHP
Disclaimer
By completing this form you fully understand that Mara Gerke is a natural health ADVISOR and TEACHER and neither claims nor implies that any instruction, advice, counsel, suggestions, recommendations, services or products she or her representatives provide, whether in person, electronically, by mail or by telephone, will cure, treat, prevent or mitigate any disease condition; but are provided solely for the purpose of increasing energy, supporting the natural function of body systems and otherwise improving general health and fitness. I understand that I am here to learn about natural health and better lifestyle practices and that I will be offered information about food supplements and herbs as a guide to general health. I understand that the decisions I make regarding my health care and the health care of those under my guardianship are my responsibility and certify that I will not hold Mara Gerke responsible for the consequences of my decisions.
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Name
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Instructions
If you have problems with any of the conditions listed below, check on the box next to it. When you have finished reviewing the list of conditions, click the submit button.This Body System Questionnaire is based on Steven Horne's A+B+C+D Course which utilizes a unique approach to restoring and maintaining health.
Please check the boxes on all statements that apply.
Abdominal Pain or Discomfort
Absent-mindedness or forgetfulness
Acid indigestion or heartburn
Anxiety, nervousness or tension
Asthma
Bad breath or body odor
Brittle fingernails
Burning or painful urination
Cold hands and feet
Colitis or other bowel irritations
Congested air passages
Constipation or dry stools
Cravings for fat or high fat diet
Cravings for sugar
Dark circles or puffiness under eyes
Difficulty getting to sleep
Dizziness or light headedness
Dry skin
Excess mucous production
Family history of heart disease
Fatigue in the afternoons
Fatigue or low energy levels
Food allergies
Food sits heavy on stomach after eating
Frequent backache
Frequent cough
Frequent infections
Frequent urinary tract infections
General weakness or chronic illness
Hayfever
Heart Problems
High blood pressure
High cholesterol
Impotency (males only)
Infertility
Intestinal gas or bloating
Itchy nose and ears
Joint pain, arthritis or gout
Leg cramps or pains
Less than 1 bowel elimination per day
Loose stool or diarrhea
Loss of appetite or poor appetite
Loss of sexual desire
Menopause Problems (Females only)
Menstrual problems(females only)
Mental/emotional stress
Migraine headaches
Muddled thinking, confusion/mental sluggishness
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Please check the boxes on all statements that apply.
Osteoporosis
Pale complexion and/or anemia
Prostate problems (males only)
Restless dreams or nightmares
Scant or excessive urination
Sinus congestion
Sinus headaches
Skin Problems (acne, rashes, etc)
Stiff, aching or painful muscles
Swollen lymph glands
Ulcers
Underweight or unable to gain weight
Urinating at night
Varicose veins
Waking up frequently at night
Water retention or edema
Weak legs, knees or ankles
Wheezing or shortness of breath
Wounds won't heal in extremities
What Color are your eyes?
Blue or Green
Light Brown or Mixed
Dark Brown, almost Black
What is your main health concern that brought you to this form today? Please include the month and/or year it began and what you think is the cause of this concern?
Please list any nutritional supplements you are taking.
How much water do you drink each day. Please answer in glasses or ounces?
Describe your typical daily diet. Please be as specific as possible. List what you eat for BREAKFAST, LUNCH, DINNER AND SNACKS. Example: Breakfast - Vegan Protein Shake with Water and Almond Milk.
Do you currently exercise? Please answer Yes or No below and if you do exerccise please describe your routine below.
Have you recently experienced any major life changes or traumatic events? (Such as moving, the loss of a loved one or pet, recently changed jobs or decided to go back to school?)
If you are under a doctor’s care for any current health conditions, please list those conditions and any medications you are taking.
Please list any allergies you may have including food, pollen, dust, pet and other:
Please list the things you have tried to help you with your current health concern. Please let me know which ones may have been beneficial.
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