The Health Evaluation Questionnaire takes about two minutes to complete. It can provide you with an objective view of your health and help you decide if you should add a nutritional supplement to your diet. The results you get today can be compared to future results by completing the questionnaire again in four weeks. You can use the comparison of the two tests to evaluate and determine your health improvement and what adjustments you can make to your diet or nutritional supplement intake to further improve your health. You may also find it useful to take the results of the questionnaire directly to your health care practitioner or physician.

After finishing the test please send us your results to texasherbcompany@yahoo.com  and we will design your complete wellness profile for free.

Thank you for being Proactive in the path of Your Wellness.

Name: ________________________________________________

Date: __________________________

Body Weight: ____________________

Birth Date and Time:___________________________________

Women Only!!!! Onset of first menstruation:________________________________________________

As a child where you (circle one):         Skinny               Moderate          Chubby  

The primary condition or symptom that I want to address is: ___________________________________

_____________________________________________________________________________________

Rate the following on a scale of 1 to 5 and circle your answer for each.

1 = No symptoms

2 = Occasional symptoms or mild symptoms

3 = Frequent symptoms or moderate symptoms

4 = Daily symptoms that are tolerable

5 = Daily symptoms that are limiting or very painful

1. 1. My eyesight 1 2 3 4 5
2. 2. My hearing 1 2 3 4 5
3. 3. My mouth, gums and teeth 1 2 3 4 5
4. 4. My throat and neck 1 2 3 4 5
5. 5. My back and shoulders 1 2 3 4 5
6. 6. My arms and legs, including elbows and knees 1 2 3 4 5

1. 7. My hands and feet, including wrists and ankles 1 2 3 4 5
2. 8. My circulation 1 2 3 4 5
3. 9. My heart and cardiovascular health 1 2 3 4 5
4. 10. My digestive tract, including stomach and colon 1 2 3 4 5
5. 11. My blood sugar level 1 2 3 4 5
6. 12. How I feel after I eat 1 2 3 4 5
7. 13. My bowel regularity 1 2 3 4 5
8. 14. My bladder and urinary tract 1 2 3 4 5
9. 15. My lungs and bronchial tubes 1 2 3 4 5
10. 16. Any allergies 1 2 3 4 5
11. 17. My skin 1 2 3 4 5
12. 18. How I feel when I wake up in the morning 1 2 3 4 5
13. 19. How I feel when I go to bed at night 1 2 3 4 5
14. 20. How often I have pain anywhere in my body 1 2 3 4 5
15. 21. How often I get headaches 1 2 3 4 5
16. 22. My reproductive organs 1 2 3 4 5
17. 23. My libido 1 2 3 4 5
18. 24. My menstrual cycle (women) or prostate (men) 1 2 3 4 5
19. 25. My emotional balance and self control 1 2 3 4 5
20. 26. My memory and mental clarity 1 2 3 4 5
21. 27. Any feelings of depression 1 2 3 4 5
22. 28. My energy levels 1 2 3 4 5
23. 29. My stamina or endurance to illness, fatigue, or stress 1 2 3 4 5
24. 30. My immune system 1 2 3 4 5

Your Health Index is a numerical value that helps you assess your current state of health based on your personal responses to the questionnaire. The LOWER the Health Index number the healthier you probably are. The HIGHER the Health Index number the more support your body needs in order to heal.

The LOWEST (and most healthy) score indicator possible is 30. The HIGHEST (and least healthy) score indicator possible is 150. A small drop in the Health Index score is significant so as you retake the questionnaire over time, note those subtle but significant and positive changes in your health.

Health improves in cycles. Because health improves in cycles, your Health Index score will increase and decrease with those cycles. An increase may be due to the flu or a minor injury. Exercising, taking a nutritional supplement, and a healthy diet require time to work. A little bit of each every day will provide better benefits to you and your body than starting and stopping.

Add up the numbers you circled for questions 1 through 30.

If you circled only 1’s and 2’s, you feel you are probably in very good health.

If you circled any 3’s but no 4’s or 5’s you feel your health is beginning to show signs of some trouble.

If you circled any 4’s you feel your health needs help right away.

If you circled any 5’s you feel your body may need a more aggressive approach to health improvement.

After a month, retake the questionnaire.

As your symptoms and health improve, your Health Index should go down. Every time you take the test, use the guidelines above to adjust your diet, exercise and nutritional supplement. 

The information and results of the questionnaire are designed to provide health information and to accompany, not replace, the services of a qualified health care practitioner or physician. Always consult your health care practitioner or physician before beginning, changing, or stopping any treatment or medication.