Dr. Stewart Edrich - Chiropractor in Los Alamitos

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Tums are not Vitamins

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Personal Information Form

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

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	Recreational Drugs Specify
Antidiabetic/Insulin	Heart Medications	Oral Contraceptive		Thyroid
Aspirin/Tylenol	High Blood Pressure	Radiation		Ulcer Medications
Aspirin/Tylenol	High Blood Pressure	Radiation	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
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1.	Bad breath, halitosis	1	2	3
2.	Loss of taste for high protein foods (meat, etc.)	1	2	3
3.	Burning (acid) or nervous stomach,eating relieves	1	2	3
4.	Gas shortly after eating	1	2	3
5.	Indigestion 1/2 to 1 hour after eating, may last 3-4 hours	1	2	3
6.	Difficulty digesting fruits or vegetables; undigested foods found in stools	1	2	3
7.	Acid or spicy foods upset stomach	1	2	3

Section B: Liver, Gallbladder Stress
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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
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24.	Coated tongue or “fuzzy” debris on tongue	1	2	3
25.	Pass large amounts of foul smelling gas	1	2	3
26.	Irritable bowel or mucous colitis	1	2	3
27.	Constipation, diarrhea alternating or stools alternate from soft to watery	1	2	3
28.	Bowel movements painful or difficult, constipation, and/or laxatives used	1	2	3
29.	Burning or itching anus	1	2	3

Allergic Stress

30.	Head congestion/sinus fullness	1	2	3
31.	Sneezing attacks	1	2	3
32.	Dreaming, nightmare-like bad dreams	1	2	3
33	Milk products and/or wheat products cause distress	1	2	3
34.	Eyes and nose watery	1	2	3
35.	Eyes swollen or puffy	1	2	3
36.	Pulse speeds after meals and/or heart pounds after retiring	1	2	3

Section: D: Blood Sugar Stress
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37.	Crave sweets or coffee in afternoon or mid-morning	1	2	3
38.	Hungry between meals or excessive appetite	1	2	3
39.	Overeating sweets upsets	1	2	3
40.	Eat when nervous	1	2	3
41.	Irritable before meals	1	2	3
42.	Get “shaky” or light-headed if meals delays	1	2	3
43.	Fatigue, eating relieves	1	2	3
44.	Heart palpitates if meals missed or delayed	1	2	3
45.	Awaken a few hours after sleep, hard to get back to sleep	1	2	3

Section: E: Vitamin Deficiency
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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
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52.	Sex drive increased	1	2	3
53.	“Splitting” type headaches	1	2	3
54.	Memory failing	1	2	3
55.	Tolerance for sugar reduced	1	2	3

Section: G: Pituitary Hormone Fatigue
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56.	Sex drive reduced or absent	1	2	3
57.	Abnormal thirst	1	2	3
58.	Weight gain around hips or waist	1	2	3
59.	Tendency to ulcers or colitis	1	2	3
60.	Increased ability to eat sugar without symptoms	1	2	3
61.	Menstrual disorders (women)	1	2	3
62.	Lack of menstruation (young girls)	1	2	3

Section: H: Thyroid Stress
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63.	Difficulty gaining weight, even if large appetite	1	2	3
64.	Heart palpitations	1	2	3
65.	Nervous, emotional, and/or can't work under pressure	1	2	3
66.	Insomnia	1	2	3
67.	Inward trembling	1	2	3
68.	Night sweats	1	2	3
69.	Fast pulse at rest	1	2	3
70.	Intolerant to high temperatures	1	2	3
71.	Easily flushed	1	2	3

Section: I: Thyroid Fatigue
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72.	Difficulty losing weight	1	2	3
73	Reduced initiative and/or mental sluggishness	1	2	3
74.	Easily fatigued, sleepy during the day	1	2	3
75.	Sensitive to cold, poor circulation (cold hands and feet)	1	2	3
76.	Dry or scaly skin	1	2	3
77.	“Ringing” in ears/noises in head	1	2	3
78.	Hearing impaired	1	2	3
79.	Constipation	1	2	3
80.	Excessive falling hair and/or coarse hair	1	2	3
81.	Headaches when awaken/wear off during day	1	2	3

Section: J: Adrenal Stress
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82.	Blood pressure increased	1	2	3
83.	Headaches	1	2	3
84.	Hot flashes	1	2	3
85.	Hair growth on face or body (women)	1	2	3
86.	Masculine tendencies (women)	1	2	3

Section: K: Adrenal Fatigue
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87.	Blood pressure low	1	2	3
88.	Crave salt	1	2	3
89.	Chronic fatigue/get drowsy	1	2	3
90.	Afternoon yawning	1	2	3
91.	Weakness/dizziness	1	2	3
92.	Weakness after colds/slow recovery	1	2	3
93.	Circulation poor	1	2	3
94.	Muscular and nervous exhaustion	1	2	3
95.	Subject to colds, asthma, bronchitis (respiratory disorders)	1	2	3
96.	Allergies and/or hives	1	2	3
97.	Difficulty maintaining manipulative correction	1	2	3
98.	Arthritic tendencies	1	2	3
99.	Nails weak, ridged	1	2	3
100.	Perspire easily	1	2	3
101.	Slow starter in morning	1	2	3
102.	Afternoon headaches	1	2	3

Section: L: Mineral depletion
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103.	Frequent skin rashes and/or hives	0	1	2	3
104.	Muscle-leg-toe cramping at rest and/or while sleeping	0	1	2	3
105.	Fever easily raised/fevers common	0	1	2	3
106.	Crave chocolate	0	1	2	3
107.	Feet have bad odor	0	1	2	3
108.	Hoarseness frequent	0	1	2	3
109.	Difficulty swallowing	0	1	2	3
110.	Joint stiffness after rising	0	1	2	3
111.	Vomiting frequent	0	1	2	3
112.	Tendency to anemia	0	1	2	3
113.	“Whites” of eyes (sclera) blue	0	1	2	3
114.	“Lump” in throat	0	1	2	3
115.	Dry mouth-eyes-nose	0	1	2	3
116.	White spots on finger nails	0	1	2	3
117.	Cuts heal slowly and/or scar easily	0	1	2	3
118.	Reduced or “lost” sense of taste and/or smell	0	1	2	3
119.	Susceptible to colds, fevers, and/or infections	0	1	2	3
120.	Strong light irritates eyes	0	1	2	3
121.	Noises in head or ringing in ears	0	1	2	3
122.	Burning sensations in mouth	0	1	2	3
123.	Numbness in hands and feet (extremities “ go to sleep”)	0	1	2	3
124.	Intolerant to monosodium glutamate (MSG)	Yes		No
125.	Cannot recall dreams	0	1	2	3
126.	Nose bleeds frequent	0	1	2	3
127.	Bruise easily, “black and blue” spots	0	1	2	3
128.	Muscle cramps, worse with exercise (“charley horses” )	0	1	2	3

Section M: Cardio Vascular Stress
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129.	Aware of heavy and/or irregular breathing	1	2	3
130.	Discomfort in high altitudes	1	2	3
131.	“Air hunger”/ sigh frequently	1	2	3
132.	Swollen ankles/worse at night	1	2	3
133.	Shortness of breath with exertion	1	2	3
134.	Dull pain in chest and/or pain radiating into left arm, worse on exertion	1	2	3

Female Only
Female Hormone Stress
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135.	Premenstrual tension	0	1	2	3
136.	Painful menses (cramping, etc.)	0	1	2	3
137.	Menstruation excessive or prolonged	0	1	2	3
138.	Painful/tender breasts	0	1	2	3
139.	Menstruate too frequently	0	1	2	3
140.	Acne, worse at menses	0	1	2	3
141.	Depressed feelings before menstruation	0	1	2	3
142.	Vaginal discharge	0	1	2	3
143.	Menses scanty or missed	0	1	2	3
144.	Hysterectomy/ovaries removed	Yes		No
145.	Menopausal hot flashes	0	1	2	3
146.	Depression	0	1	2	3

Men Only
Male Hormone Stress
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147.	Prostate trouble	1	2	3
148.	Urination difficult or dribbling	1	2	3
149.	Night urination frequent	1	2	3
150.	Pain on inside of legs or heels	1	2	3
151.	Feeling of incomplete bowel evacuation	1	2	3
152.	Leg nervousness at night	1	2	3
153.	Tire easily/avoid activity	1	2	3
154.	Reduced sex drive	1	2	3
155.	Depression	1	2	3
156.	Migrating aches and pains	1	2	3

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