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By completing this form, the cardholder agrees to pay the $30.00 non-refundable fee to Dr. John B. Avard, Bedford, NH, in accordance with the card issuer agreement.  It is also agreed and understood that Dr. John B. Avard is providing a data entry and reporting service, and that this service in no way constitutes the provision of medical/chiropractic advise nor treatment.  This service is provided strictly to report the users recommended nutritional supplementation as related to natural dietary supplements.  No warrantees or guarantees are expressed or implied.  This is not a diagnostic service.  If you are in need of medical/chiropractic evaluation or services, please seek the immediate help of a licensed practitioner near you.

THERE ARE 197 QUESTIONS, IT MAY TAKE YOU A WHILE

 PLEASE BE PATIENT.

GROUP 1    1.  Acid foods upset stomach      2.  Get chilled, often      3.  "Lump" in throat      4.  Dry mouth-eyes-nose      5.  Pulse speeds after meals     6.  Keyed up -- Fail to calm      7.  Cuts heal slowly      8.  Gag easily    9.  Unable to relax; startles easily     10.  Extremities cold, clammy   11.  Strong lights irritate   12.  Urine amount reduced     13.  Heart pounds after retiring    14.  "Nervous" stomach   15.  Appetite reduced   16.  Cold sweats often   17.  Fever easily raised   18.  Neuralgia-like pains    19.  Staring, blinks little   20.  Frequent sour stomach GROUP 2   21.  Joint stiffness after arising   22.  Muscle-Leg-Toe cramps at night   23.  "Butterfly" stomach, cramps   24.  Eyes or nose watery   25.  Eyes blink often   26.  Eyelids swollen, puffy   27.  Indigestion soon after meals   28.  Always seems hungry; often feels "lightheaded"   29.  Digestion rapid   30.  Frequent vomiting   31.  Frequent hoarseness   32.  Irregular breathing   33.  Slow pulse; feels "irregular"   34.  Gagging reflex slow   35.  Difficulty swallowing   36.  Alternating constipation and diarrhea   37.  "Slow starter"   38.  Get "chilled" infrequently   39.  Perspire easily   40.  Poor circulation, sensitive to cold   41.  Subject to colds, asthma, bronchitis GROUP 3   42.  Eat when nervous   43.  Excessive appetite   44.  Hungry between meals   45.  Irritable between meals   46.  Get "shaky" if hungry   47.  Eating relieves fatigue   48.  "Lightheaded" if meals delayed   49.  Heart palpitates if meals missed or delayed   50.  Afternoon headaches   51. Overeating sweets upsets   52. Awaken after a few hours sleep -- hard to get back to sleep   53. Crave candy or coffee in afternoons   54. Moods of depression -- "blues" or melancholy   55. Abnormal craving for sweets or snacks GROUP 4   56. Hands and feet go to sleep easily, numbness   57. Sigh frequently, "air hungry"   58. Aware of "breathing heavy"   59. High altitude discomfort   60. Opens windows in closed room   61. Susceptible to colds and fevers   62. Afternoon "yawner"   63. Get "drowsy" often   64. Swollen ankles at night   65. Muscle cramps, worse during exercise; get "charley horse"   66. Shortness of breath on exertion   67. Dull pain in chest or radiating into left arm, worse on exertion   68. Bruise easily, "black/blue" spots   69. Tendency to anemia   70. Frequent nose bleeds   71. Noises in head or ringing in ears   72. Tension under the breastbone, or feeling of "tightness", worse on exertion GROUP 5   73. Dizziness   74. Dry skin   75. Burning feet   76. Blurred vision   77. Itching skin and feet   78. Excessive falling hair   79. Frequent skin rashes   80. Bitter, metallic taste in mouth in mornings   81. Bowel movements painful or difficult   82. Worrier, feels insecure   83. Feels queasy, headache over eyes   84. Greasy foods upset   85. Light-colored stools 86. Skin peels on foot soles   87. Pain between shoulder blades   88. Use laxatives   89. Stools alternate from soft to watery   90. History of gallbladder attacks or gallstones   91. Sneezing attacks   92. Dreaming, nightmare type bad dreams   93. Bad breath (halitosis)   94. Milk products cause distress   95. Sensitivity to hot weather   96. Burning or itching anus   97. Crave sweets GROUP 6   98.  Loss of taste for meat   99.  Lower bowel gas several hours after eating 100.  Burning stomach sensations, relieved by eating 101.  Coated tongue 102.  Pass large amounts of foul smelling gas 103.  Indigestion 1/2 to 1 hour after eating; may be up to 3-4 hours 104.  Mucus colitis or "irritable bowel" 105. Gas shortly after eating 106.  Stomach "bloating" after eating GROUP 7 (A) 107.  Insomnia 108. Nervousness 109. Can't gain weight 110.  Intolerance to heat 111.  Highly emotional 112.  Flush easily 113.  Night sweats 114.  Thin, moist skin 115.  Inward trembling 116.  Heart palpitates 117.  Increased appetite without weight gain 118.  Pulse fast at rest 119.  Eyelids and face twitch 120.  Irritable and restless 121.  Can't work under pressure (B) 122.  Increase in weight 123.  Decrease in appetite 124.  Fatigue easily 125.  Ringing in ears 126.  sleepy during day 127.  Sensitive to cold 128.  Dry or scaly skin 129.  Constipation 130.  Mental sluggishness   131.  Hair coarse, falls out 132.  Headaches upon arising, wear off during the day 133.  Slow pulse, below 65 134.  Frequent urination 135.  Impaired hearing 136.  Reduced initiative (C) 137.  Failing memory 138.  Low blood pressure 139.  Increased sex drive 140.  Headaches, "splitting or rending" type 141.  Decreased sugar tolerance (D) 142.  Abnormal thirst 143.  Bloating of the abdomen 144.  Weight gain around hips or waist 145.  Sex drive reduced or lacking 146.  Tendency to ulcers, colitis 147.  Increased sugar tolerance 148.  Women: Menstrual disorders 149.  Young Girls: Lack of menstrual function (E) 150.  Dizziness 151.  Headaches 152.  Hot flashes 153.  Increased blood pressure 154.  Hair growth on face or body (female) 155.  Sugar in urine (not diabetes) 156.  Masculine tendencies (female) (F) 157.  Weakness, dizziness 158.  Chronic fatigue 159.  Low blood pressure 160.  Nails weak, rigid 161.  Tendency to hives 162.  Arthritic tendencies 163.  Increased perspiration 164.  Bowel disorders 165.  Poor circulation 166.  Swollen ankles 167.  Crave salt 168.  Brown spots or bronzing of skin 169.  Allergies--tendency to asthma 170.  Weakness after colds, influenza 171.  Exhaustion--muscular and nervous 172.  Respiratory disorders FEMALE ONLY 173.  Very easily fatigued 174.  Premenstrual tension 175.  Painful menses 176.  Depressed feelings before menstruation 177.  Menstruation excessive and prolonged 178.  Painful breasts 179.  Menstruate too frequently 180.  Vaginal discharge 181.  Hysterectomy/ovaries removed 182.  Menopausal hot flashes 183.  Menses scanty or missed 184.  Acne, worse at menses 185.  Depression of long standing MALE ONLY 186.  Prostate trouble 187.  Urination difficult or dribbling 188.  Frequent night urination 189.  Depression 190.  Pain on inside of legs or heels 191.  Feeling of incomplete bowel evacuation 192.  Lack of energy 193.  Migrating aches and pains 194.  Tire too easily 195.  Avoids activity 196.  Legs nervous at night 197.  Diminished sex drive