BP:    /

    Pulse:   

    Test Date:   

    Time Of Test:    6:30 am-7:29 am 7:30 am-8:29 am 8:30 am-9:29 am 9:30 am-10:29 am 10:30 am- 11:29 am 11:30 am- 12:29 pm 12:30 pm- 1:29 pm 1:30 pm - 2:29 pm 2:30 pm- 3:29 pm 3:30 pm- 4:29 pm 4:30 pm- 5:29 pm 5:30 pm- 6:29 pm 6:30 pm- 7:29 pm

    Sugar:   

    Urine pH/ Saliva pH: /

    Salts:   

    Cell Debris:   

    Nitrate/ Ammonia:     /

    Comments:

Click here to skip remaining sections and submit the above data if submitting BIA data only.

Section 4: MemGram® Questionnaire #1:

Rate each statement 0-5 according to the intensity of how you have recently felt.
0=Never 1=Rarely 2=Occasionally 3=Regularly 4=Often 5=Very Often

1.     0 1 2 3 4 5 I use prescription, non-prescription, or recreational drugs.

2.     0 1 2 3 4 5 I consume alcoholic beverages.

3.     0 1 2 3 4 5 I use tobacco products (cigarettes, cigars, etc.)

4.     0 1 2 3 4 5 I get excited easily.

5.     0 1 2 3 4 5 I sigh or sob.

6.     0 1 2 3 4 5 I have little strength.

7.     0 1 2 3 4 5 I just don't care.

8.     0 1 2 3 4 5 I am aroused sexually.

9.     0 1 2 3 4 5 I get cold sweats.

10.   0 1 2 3 4 5 I have hot flashes.

11.   0 1 2 3 4 5 I have excessive reactions.

12.   0 1 2 3 4 5 I protect what is mine.

13.   0 1 2 3 4 5 I won't take "no" for an answer.

14.   0 1 2 3 4 5 I over exert myself.

15.   0 1 2 3 4 5 I am assertive.

16.   0 1 2 3 4 5 I am fatigued.

17.   0 1 2 3 4 5 I wish I were braver.

18.   0 1 2 3 4 5 I am anxious.

19.   0 1 2 3 4 5 I feel worn out by others.

20.   0 1 2 3 4 5 I prefer not discussing my symptoms.

21.   0 1 2 3 4 5 I am un-accepting of others.

22.   0 1 2 3 4 5 I need a breath of fresh air.

23.   0 1 2 3 4 5 I have been traumatized.

24.   0 1 2 3 4 5 People easily provoke me.

25.   0 1 2 3 4 5 I have difficulty breathing in rhythm.

26.   0 1 2 3 4 5 I am not receptive to the opinions of others.

27.   0 1 2 3 4 5 I am heartbroken.

28.   0 1 2 3 4 5 I am deprived of love.

29.   0 1 2 3 4 5 I am very codependent.

30.   0 1 2 3 4 5 I feel unwanted.

31.   0 1 2 3 4 5 My situation angers me.

32.   0 1 2 3 4 5 I use bad language.

33.   0 1 2 3 4 5 I am critical of others.

34.   0 1 2 3 4 5 I have little patience.

35.   0 1 2 3 4 5 I lose control of my anger.

36.   0 1 2 3 4 5 I feel unappreciated.

37.   0 1 2 3 4 5 I am offended by other's achievements.

38.   0 1 2 3 4 5 I feel entitled to what others have.

39.   0 1 2 3 4 5 I don't get the recognition I deserve.

40.   0 1 2 3 4 5 I feel no longer needed.

41.   0 1 2 3 4 5 I harbor grievances.

42.   0 1 2 3 4 5 I strongly hold to my opinions.

43.   0 1 2 3 4 5 My problems are caused by others.

44.   0 1 2 3 4 5 I let people get under my skin.

45.   0 1 2 3 4 5 I hate my circumstances.

46.   0 1 2 3 4 5 I have wet palms

47.   0 1 2 3 4 5 I am unable to relax after the least amount of exercising.

48.   0 1 2 3 4 5 I lack confidence.

49.   0 1 2 3 4 5 I have been laid off or fired.

50.   0 1 2 3 4 5 Someone close to me is missing.

51.   0 1 2 3 4 5 I am slow to learn new things.

52.   0 1 2 3 4 5 Life is difficult for me.

53.   0 1 2 3 4 5 I see only the good things.

54.   0 1 2 3 4 5 I am not pleased.

55.   0 1 2 3 4 5 My stomach feels distended.

56.   0 1 2 3 4 5 I have dreadful thoughts.

57.   0 1 2 3 4 5 I think too much.

58.   0 1 2 3 4 5 I need answers.

59.   0 1 2 3 4 5 The unfamiliar disturbs me.

60.   0 1 2 3 4 5 Things concern me.

61.   0 1 2 3 4 5 I lack body warmth.

62.   0 1 2 3 4 5 My blood pressure runs high.

63.   0 1 2 3 4 5 My head aches when I think.

64.   0 1 2 3 4 5 I have trouble remembering things.

65.   0 1 2 3 4 5 I wake frequently at night to urinate.

66.   0 1 2 3 4 5 I feel out of harmony.

67.   0 1 2 3 4 5 I need to be the one in charge.

68.   0 1 2 3 4 5 I feel manipulated.

69.   0 1 2 3 4 5 I feel heaviness in my upper body.

70.   0 1 2 3 4 5 My arms and legs move slowly.

71.   0 1 2 3 4 5 I feel overwhelmed and stressed out.

72.   0 1 2 3 4 5 I suffer from low endurance.

73.   0 1 2 3 4 5 I have unknown health concerns.

74.   0 1 2 3 4 5 It's not easy to "laugh it off".

75.   0 1 2 3 4 5 My facial expressions are unique.

76.   0 1 2 3 4 5 I am easily annoyed.

77.   0 1 2 3 4 5 I don't like being alone.

78.   0 1 2 3 4 5 I feel gloomy.

79.   0 1 2 3 4 5 I feel fatigued after meals.

80.   0 1 2 3 4 5 I feel down in the dumps.

81.   0 1 2 3 4 5 I have a lack of interest.

82.   0 1 2 3 4 5 I would like to experience a change.

83.   0 1 2 3 4 5 It is difficult to put things in perspective order.

84.   0 1 2 3 4 5 Situations seem to run together making it difficult to separate them.

85.   0 1 2 3 4 5 I get the shakes and quivers.

86.   0 1 2 3 4 5 I would like to feel more energetic.

87.   0 1 2 3 4 5 I am aging too quickly.

88.   0 1 2 3 4 5 I feel drained.

89.   0 1 2 3 4 5 I have reactions to radiation (i.e. sun, heat, microwaves, x-rays, etc.)

90.   0 1 2 3 4 5 It is difficult for me to stay focused.

91.   0 1 2 3 4 5 I feel trapped.

92.   0 1 2 3 4 5 I am bored with my usual schedule.

93.   0 1 2 3 4 5 I feel like I'm suffocating.

94.   0 1 2 3 4 5 I have obstacles in my way.

95.   0 1 2 3 4 5 Sometimes I have difficulty breathing.

96.   0 1 2 3 4 5 I startle easily.

97.   0 1 2 3 4 5 I am not relaxed

98.   0 1 2 3 4 5 I do not have peace of mind.

99.   0 1 2 3 4 5 I am easily awakened.

100. 0 1 2 3 4 5 I have unfinished business.

101. 0 1 2 3 4 5 I wish I could disappear.

102. 0 1 2 3 4 5 I suffer from unexplained worries

103. 0 1 2 3 4 5 I put excessive consideration into what I eat.

104. 0 1 2 3 4 5 I am bashful, withdrawn, or inhibited.

105. 0 1 2 3 4 5 I feel queasy when under pressure.

106. 0 1 2 3 4 5 I feel hindered.

107. 0 1 2 3 4 5 I am sensitive to changes in temperature.

108. 0 1 2 3 4 5 I keep my problems to myself.

109. 0 1 2 3 4 5 I feel stressed from work.

110. 0 1 2 3 4 5 I don't voice my opinion.

111. 0 1 2 3 4 5 I am sexually inadequate.

112. 0 1 2 3 4 5 I have poor equilibrium.

113. 0 1 2 3 4 5 I feel a continuous desire for food.

114. 0 1 2 3 4 5 I don't feel like myself lately.

115. 0 1 2 3 4 5 I need more stability in my life.

116. 0 1 2 3 4 5 I am worried.

117. 0 1 2 3 4 5 I am absent minded.

118. 0 1 2 3 4 5 I feel woozy or faint.

119. 0 1 2 3 4 5 I am afraid.

120. 0 1 2 3 4 5 I don't deal well with pressure.

Section 4 Continued: MemGram® Questionnaire #2

Rate each statement 0-5 according to the intensity of how you have recently felt.
0=Never 1=Rarely 2=Occasionally 3=Regularly 4=Often 5=Very Often

1.   0 1 2 3 4 5 I need prescription, non-prescription, or recreational drugs.

2.   0 1 2 3 4 5 I am emotionally unbalanced.

3.   0 1 2 3 4 5 My periods are irregular (female).

4.   0 1 2 3 4 5 My crotch itches.

5.   0 1 2 3 4 5 I have festering or phlegm.

6.   0 1 2 3 4 5 I feel swollen.

7.   0 1 2 3 4 5 I have pains in particular places.

8.   0 1 2 3 4 5 I have pain, redness, or swelling.

9.   0 1 2 3 4 5 I get sick easily.

10. 0 1 2 3 4 5 I can't stay focused or concentrate.

11. 0 1 2 3 4 5 I am slowly losing energy.

12. 0 1 2 3 4 5 I suffer from asthmatic attacks.

13. 0 1 2 3 4 5 I suffer from bronchitis.

14. 0 1 2 3 4 5 My chest hurts.

15. 0 1 2 3 4 5 I have tightness in my chest.

16. 0 1 2 3 4 5 I have thrombosis.

17. 0 1 2 3 4 5 I have heart tremors.

18. 0 1 2 3 4 5 My temples throb.

19. 0 1 2 3 4 5 I have decayed teeth and bones.

20. 0 1 2 3 4 5 I suffer from arthritic changes.

21. 0 1 2 3 4 5 I have seizures or convulsions.

22. 0 1 2 3 4 5 Cataracts obstruct my vision.

23. 0 1 2 3 4 5 My bones are brittle.

24. 0 1 2 3 4 5 I have bleeding piles or hemorrhoids.

25. 0 1 2 3 4 5 I have itching piles or hemorrhoids.

26. 0 1 2 3 4 5 I have fissures of the anus.

27. 0 1 2 3 4 5 I have piles or hemorrhoids.

28. 0 1 2 3 4 5 I have bulging leg veins.

29. 0 1 2 3 4 5 I have loose bowel movements.

30. 0 1 2 3 4 5 I have an irritated and spastic colon.

31. 0 1 2 3 4 5 My stool contains mucous.

32. 0 1 2 3 4 5 I use bowel stimulants.

33. 0 1 2 3 4 5 Bowel movements cause weakness.

34. 0 1 2 3 4 5 I have sticky perspiration.

35. 0 1 2 3 4 5 I have excessive perspiration.

36. 0 1 2 3 4 5 My body odor is strong.

37. 0 1 2 3 4 5 I have digestive disorders.

38. 0 1 2 3 4 5 I burp, belch or have gas after eating.

39. 0 1 2 3 4 5 I get a sour stomach or heartburn.

40. 0 1 2 3 4 5 I have stomach pain after eating.

41. 0 1 2 3 4 5 I feel bloated.

42. 0 1 2 3 4 5 I get congested (ears, sinus, head).

43. 0 1 2 3 4 5 I get earaches.

44. 0 1 2 3 4 5 I get severe headaches.

45. 0 1 2 3 4 5 I have radiating nerve pain.

46. 0 1 2 3 4 5 I suffer from influenza.

47. 0 1 2 3 4 5 My arms and legs hurt.

48. 0 1 2 3 4 5 I get sinus congestion.

49. 0 1 2 3 4 5 I feel pressure in my chest.

50. 0 1 2 3 4 5 I am susceptible to colds.

51. 0 1 2 3 4 5 My glands are swollen.

52. 0 1 2 3 4 5 I complain and am easily irritated.

53. 0 1 2 3 4 5 I always want to eat.

54. 0 1 2 3 4 5 I have dark urine or yellow skin.

55. 0 1 2 3 4 5 I have problems with my gallbladder.

56. 0 1 2 3 4 5 I have skin problems.

57. 0 1 2 3 4 5 My skin is irritated (itches).

58. 0 1 2 3 4 5 I have problem fingernails (eruptions, outbreaks).

59. 0 1 2 3 4 5 I get sores around my ears.

60. 0 1 2 3 4 5 I have skin disorders (warts, moles, etc.).

61. 0 1 2 3 4 5 I have coughing spells.

62. 0 1 2 3 4 5 My voice is strained or hoarse.

63. 0 1 2 3 4 5 I have seasonal allergies (hay fever).

64. 0 1 2 3 4 5 I feel like I am being strangled.

65. 0 1 2 3 4 5 I can't sleep.

66. 0 1 2 3 4 5 I wake up tired even after a good nights sleep.

67. 0 1 2 3 4 5 I have sharp low back pain.

68. 0 1 2 3 4 5 I have sharp bladder pain.

69. 0 1 2 3 4 5 I have bladder problems (incontinence).

70. 0 1 2 3 4 5 It hurts to urinate.

71. 0 1 2 3 4 5 I am sensitive to temperate changes.

72. 0 1 2 3 4 5 I have chronic lower back condition.

73. 0 1 2 3 4 5 I suffer from arthritic changes.

74. 0 1 2 3 4 5 I have pain in my lower back.

75. 0 1 2 3 4 5 I have poor digestion.

76. 0 1 2 3 4 5 I have high blood sugar (diabetes).

77. 0 1 2 3 4 5 I have low blood sugar (hypoglycemia).

78. 0 1 2 3 4 5 I am allergic.

79. 0 1 2 3 4 5 Walking is not easy for me.

80. 0 1 2 3 4 5 I have anxiety or fear.

Click here to skip remaining sections and submit the above data if submitting MemGram® data only.

Section 5: Specific Symptomatology

Please select only the descriptions which apply.

1.     Rectal, nose or jock itch

2.     Gout

3.     Emphysema

4.     Tumors or cysts

5.     Heart Disease

6.     Atherosclerosis or Arteriosclerosis

7.     Athlete's Foot or Ringworm

8.     Infections

9.     Tonsils Removed

10.   Appendix Removed

11.   STD's (Sexually Transmitted Diseases)

12.   Bronchitis

13.   Diabetes

14.   Hypoglycemia

15.   Kidney or Bladder Problems

16.   Liver or Gall Bladder Problems

17.   Thyroid Problems

18.   Problem with Alcohol

19.   Exposed to Heavy Metals (dyes, chemical, aluminum, cookware, pollution, etc.)

20.   Stools Show Undigested Food

21.   Nausea, Dizziness, Headaches

22.   Gallstones

23.   Hepatitis or Jaundice

24.   Feet Peel, Burn or Itch

25.   Varicose Veins or Hemorrhoids

26.   Onions, Cabbage, Radishes, Cucumbers Upset System

27.   Fats, Grease Upset System

28.   Bowel Movements Yellow, Clay-colored, Float, or Foul-odor

29.   Skin Gray or Pasty

30.   Skin Oily

31.   Bad Breath, Body Odor

32.   Constipation

33.   Skin Rashes

34.   Pain Under Right Rib Cage

35.   History of Cancer

36.   Reaction to Milk Products

37.   Reaction to Vinegar

38.   Reaction to Bicarbonate

39.   Bruise Easily

40.   Tension in Chest, Chest Pain

41.   Pain in Left Arm

42.   Cold Hands and/or Feet

43.   Short of Breath Climbing

44.   Short of Breath

45.   Require Extra Sleep

46.   Drowsy Often

47.   Low Exercise Tolerance

48.   High Blood Pressure

49.   Sigh Frequently

50.   Breathe Loudly

51.   High Altitude Bothers

52.   Nose Bleeds Often

53.   Ringing in Ears

54.   Pain in Left Shoulder

55.   Pain in Left Side Abdomen

56.   Blurry Left Eye

57.   Phlebitis

58.   Asthma

59.   Shingles

60.   Feet Cold, Sweaty

61.   White Spots on Fingernails

62.   Psoriasis

63.   Thirsty, Night Sweats

64.   Tired, Low Resistance

65.   Boils, Corns, Leg Sores

66.   Lesions Heal Slowly

67.   Crave Sweets

68.   Excessive Urination

69.   Always Hungry

70.   Intense Itching

71.   Burning Urine

72.   Low Backache

73.   Blood or Pus in Urine

74.     Use Diuretics

75.   Ankles or Eyelids Swell

76.   Nervous, Shaky, Headaches