Saliva Test Form

Saliva Information Form

These Programs change vital energy levels. Therefore, you may wish to
communicate with your doctor that your medication needs may fluctuate.

Date:____________ Name:__________________________________________

Address:_______________________ City:________________State:___ Zip_____

Home Phone:_________________ Work Phone:__________________

Email Address:_________________________________

Sex:_______ Age:_______ Height _______Weight:________ Family Status:_________

Blood Type _________ (A, AB, O, B)

Recommended By:__________________________

What is the medical diagnosis of your present condition? _________________________________________________________________

_________________________________________________________________

Neurological

[ ] Difficulty with reading, spelling, mathematics, comprehension, etc.
[ ] Trembling of arms or legs
[ ] Arm or leg cramps (right - left)
[ ] Epilepsy*, MS*, MD*, etc
[ ] Convulsions
[ ] Numbness in parts of body? Where?__________________
[ ] Staggering gait, unsteady
[ ] Other

Inflammations

[ ] Prone to arthritis* / rheumatism* where?______
[ ] Susceptible to infections
[ ] Sores that do not heal
[ ] Fungus infections
[ ] Diagnosed cancer

Digestion - Intestines

[ ] Nausea
[ ] Vomiting, when? ______
[ ] Stomach or duodenal ulcer
[ ] Gastro-intestinal disorder, describe ______________
[ ] Diarrhea - Constipation
[ ] Hemorrhoids
[ ] Others, describe _____
____________________

Circulation - Heart

[ ] Blood pressure, high
[ ] Blood pressure, low
[ ] Feel cold inside
[ ] Pulse abnormal
[ ] General blood disorders
____________________

Circulation Continued

[ ] Anemia*
[ ] Hemorrhage*
[ ] High Cholesterol*
[ ] Arteriosclerosis*
[ ] Heart rhythm malfunction* _______________________
[ ] Heart valve malfunction* _______________________
[ ] Angina*

Hormones - Blood Sugar

[ ] Blood sugar test* (high - low)
[ ] Diabetes* Type___________
[ ] Momentary dizziness when rising
[ ] Fatigue, low energy
[ ] Taking hormones_________ ..________________________
[ ] Weight difficulties ________
[ ] Glandular swelling _______
[ ] Thyroid malfunctions*

Female

[ ] Miscarry, when? _________
[ ] Soreness or itching vagina
[ ] Premenstrual tension
[ ] Menstrual cramps
[ ] Disorder of reproduction organs ___________________
[ ] Foul odor of discharge
[ ] Use oral contraceptive
[ ] Use diaphragm
[ ] Use Mucous method
[ ] Presently (nursing - pregnant)
[ ] Sore breast
[ ] Tumors*, type, where? ________________________

Male

[ ] Prostrate disorder*
[ ] Difficulty in urination

Structure:
Arms - Legs - Back

[ ] Fused joints*
[ ] Broken bones*
[ ] Back pains
[ ] Bones ache, where?______
________________________
[ ] Swelling (legs-arms-ankles-feet)
[ ] (Arms - legs) stiff
[ ] Varicose veins or phlebitis*
[ ] Shooting pains (legs - arms)
[ ] Leg short (right - left)
[ ] Painful or weak muscles, where?___________________
[ ] Muscle stiffness __________
[ ]Painful (hands - feet)
[ ] Fibromylgia, how long?____________

Ears

[ ] Ear discharge
[ ] Sensitive to noise
[ ] Impaired hearing
[ ] Ear noises, ringing, buzzing
[ ] Ear pains

Emotions

[ ] Emotional instability, when? __________________________
__________________________
________________________

Environment

[ ] Frequently use prescription or nonprescription drugs? Type? ___________________
[ ] Consume non-Organic foods daily
[ ] Exposed to (TV, Computer terminals, Microwaves)
[ ] Exposed to industrial chemicals, Describe_______
________________________
[ ] Use (hair sprays, deodorants, perfumes, makeup)
[ ] Do you have a water purifier? What kind? ______________

Eyes

[ ] Twitching of eyelids
[ ] Cataracts*, glaucoma*
[ ] Inability to see in dim light
Sensitive to bright light
[ ] Abnormality of eyes _______________________
[ ] Near - Far sighted

Gallbladder

[ ] Gallstones*
[ ] Cannot digest oils
[ ] Gallbladder removed

Respiration

[ ] Congestion with breathing
[ ] Breathing short and rapid
[ ] Emphysema*, asthma*
[ ] Other _______________

Lymphatic System

[ ] Get one-sided headaches, where? _______________
[ ] Other lymphatic problems ______________________

Please list all drugs and nutrients that you are using

__________________
__________________
__________________
__________________

Kidney - Bladder

[ ] Kidney stones*
[ ] *Increase - Decrease
[ ] Bed wetting
[ ] Leaking urine
[ ] Urethra - ureter inflammation
[ ] Kidney - Bladder inflammation
[ ] Blood Urine

Skin

[ ] Roughness, rashes, or scaliness of skin. Where? ______________________
[ ] Acne* or pimples
[ ] Bruise easily
[ ] Oily or greasy skin, where? ______________________
[ ] Tender skin

Basic Evaluation Includes

Food sensitivities, nutritional needs, 5 system actual and potential statistical evaluation plus emotional phase. Call Patti for this month's special price.