Dina Charmokly Health Evaluation Form

Dr Wallach's Health Evaluation Form
Name*

First NameLast Name
E-mail*
Phone Number*
Do you already have a Preferred Youngevity supplier?*

YesNo
Please rate yourself on the health symptoms below. The Health Category in which you rate the highest indicates which Healthy Body Start Pak suits you best.

This Evaluation form is intended as a guideline for nutritional support. Please consult with your health practitioner for medical diagnosis.
Category 1. Hard Tissue - Do you have:

Knee, Shoulder, Joint Pain*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Back Pain, Neck Pain*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Stiff Shoulders, Headaches*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Numbness, foot/arm fall asleep*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Trouble getting to sleep*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Bleeding Gums, Cavities*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Kidney Stones, Bone Spurs*

	0	1	2	3	4	5

0 is Never, 5 is Severe

High or low Blood Pressure*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Muscle Cramps*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Panic Attacks*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Irritability*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Nervousness*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Depression*

	0	1	2	3	4	5

0 is Never, 5 is Severe

PMS*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Osteoporosis*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Restless legs*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Do you take any of the following...

Pain Killers for any of the above ailmentsBlood Pressure medication
Hard Tissue Category Total
Category 2 Soft Tissue - Do you have:

Dry Skin, Dry Cuticles*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Skin Allergies*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Cracks on your Heels*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Forget things you go to get*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Can't remember a specific word*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Trouble Breathing*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Cough, Dry Throat*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Tiredness, Kidney Problems*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Eye or Eyesight Problems (Cataracts, Macular Degeneratio Glaucoma,etc)n,*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Age Spots, Blemishes*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Do you take any of the following...

Pain Killers for any of the above ailmentsCholesterol medicationBlood ThinnersMedication for hormonesFibromyalgia, MS medicationAlzheimers, ALS, Parkinson medsDiuretcs
Soft Tissue Category Total
Category 3. Blood Sugar - Do you have:

Cravings for sugar, sweets*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Get sleepy after meals*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Excessive Thirst or Sweating*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Wake up during the night*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Night Sweats*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Adrenal Failure*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Low Blood Sugar*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Fatigue*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Anxiety*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Fainting Spells*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Sweat Excessively*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Learning Disabilities*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Trouble Losing Weight*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Hyperactivity*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Do you take any of the following...

Blood Sugar medicationMood swing / depression medicationADD, ADHD, Autism medicationBipolar Disorder
Blood Sugar Category Total
Category 4. Digestion - Do you have:

Heartburn/Acid Reflux*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Stomach/Intestinal Pain*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Bloating/Gas*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Feel better when you don't eat*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Food Allergies*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Seasonal Allergies*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Constipation*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Diarrhoea*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Immune System Problems*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Athlete's Foot*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Burping*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Ulcers*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Get Sick (Cold/Flu)*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Dermatitis*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Nausea*

	0	1	2	3	4	5

0 is Never, 5 is Severe

Do you take any of the following...

Antacids, stomach acid medsFibre / medication for constipationMedication for Crohn's Disease
Digestion Category Total
Weight in kgs
Or Weight in lbs
Please check the total of each health category. The category you scored highest in indicates the nutritional support you need. If you score high in multiple areas you need Digestion support as this indicates you are having issues with absorption of nutrients in your food.

Click here for Hard Tissue Category nutritional support

Click here for Soft Tissue Category nutritional support.

Click here for Blood Sugar Category nutritional support

Click here for Digestion Category nutritional support

Please consult your health practitioner for medical diagnosis.
Is there anything else you would like to improve about your health?

More energyCrohn's DiseaseHeart Disease preventionImprove stamina & mental functioning in my careerAnti-AgingCancer PreventionMore energy and/or endurance while exercising or playing sportsReduce frequency of sports related injuries
Click the link below to Submit your form and one of our team will call you to discuss your Health Evaluation results.

Check your email Inbox and/or Spam folder for a copy of your Evaluation Form results.
Should be Empty:

Category 1. Hard Tissue - Do you have:

Category 2 Soft Tissue - Do you have:

Category 3. Blood Sugar - Do you have:

Category 4. Digestion - Do you have: