Fillable Male / Female

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Male / Female

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  • 562 check-boxes
  • 104 other fields

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File type: PDF

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Weight: (lbs)
How Many Bowel Movements do You Have Daily?
What does your current daily diet consist of?
Please be as honest as possible.
Snack:
Dinner:
Lunch:
Breakfast:
1.
5.
6.
2.
Are you taking any medications? Please list individually below:
3.
7.
4.
8.
(Circle One) I currently use Dr. Morse's Formulas /
I have used Dr. Morse's Formulas in the past / I have never used Dr. Morse's Formulas before
Resting Pulse: (bpm) Basal Temp. (F) Urine pH: Saliva pH:
Blood Pressure: Right: Left:
Eye Color: (Select One) Brown
Blue
2.
6.
8.
4.
7.
3.
5.
1.
Are you taking any Herbal Products or Supplements? Please list individually below:
Vitals:
Email Address:
Skype Name:
Home Address: City: State:
Zip Code: Country: Province:
Your Counselor may recommend Glandulars to
'power punch'
certain areas. Please select your preference for Glandular
recommendations: (Circle One) Preferred Not Preferred
First Name:
Height: (ft) (in)
Last Name:
Gender:
Male / Female
Age:
Home Phone # ( )
Cell Phone # ( )
Self-Assessment Health Questionnaire
A Private Sector Private Health Club
1
Date:
Are you currently filtering?
Yes
No
0 1
2 3 4+
Updated Jan. 2021
Year:
Year:
Year:
Year:
Year:
Sister/Brother:
What do you hope to gain from this program?
Maternal Grandmother:
Maternal Grandfather:
Paternal Grandmother:
Paternal Grandfather:
Previous Surgical Procedures
Please list all surgical procedures, minor or major, along with the year
Sister/Brother:
Sister/Brother:
Sister/Brother:
Genetic / Family History
Please list all known health concerns for each family member. Leave blank if you aren't sure.
Mother:
Father:
What are your primary health concerns? Please be as detailed as possible.
2
Updated Jan. 2021
Cold Hands or Feet Current Past N/A
Frequently Cold / Difficulty Warming Current Past N/A
Cold, but Burning Inside? Current Past N/A
Easy to Gain Weight and Hard to Lose It Current Past N/A
Current Past N/A
Headaches / Migraines Current Past N/A
Easily Irritable Current Past N/A
Overweight Current Past N/A
Low Energy / Always Tired Current Past N/A
Goiter / Hashimoto's / Grave's /
Reidel's Disease
Current Past N/A
Family Member with Goiter / Hashimoto's /
Grave's /Reidel's Disease
Current Past N/A
How Much do You Sweat? Low Medium Excessive
Are Your Fingernails: (Check all Applicable) Ridged Brittle Weak
Varicose Veins / Spider Veins
Current Past N/A
Hemorrhoids / Prolapses
Current Past N/A
Muscle Cramps / Legs Tire Easily Current Past N/A
Is Your Bladder:
Strong
A Few Leaks
Weak
Hernia Current Past N/A
Aneurysm Current Past N/A
Low Bone Density / Low Calcium
Current Past N/A
Osteoporosis / Scoliosis / Kyphosis /
Lordosis
Current Past N/A
Current Past N/A
Spinal Deterioration / Herniated Discs /
Bone Spurs
Current Past N/A
Bruise Easy Current Past N/A
Do you, or have you ever had difficulty with any of the following?
Please circle all applicable, and indicate: Current, Past, or N/A
Thyroid/ Glandular System
Parathyroid
0
3
Updated Jan. 2021
Slow Digestion Current Past N/A
Food Passes Quickly Through You (Diarrhea) Current Past N/A
Acid Reflux / Heartburn / Indigestion
Current Past N/A
Undigested Food in Stool Current Past N/A
Thin / Difficulty Gaining Weight Current Past N/A
Moles (Also Adrenals) Current Past N/A
Overweight Current Past N/A
MS / ALS / Parkinson's / Palsy
Current Past N/A
Anxiety Current Past N/A
Excessive Shyness / Inferiority Complex Current Past N/A
Tremors / Nervous Legs Current Past N/A
High Blood Pressure (Also Cardiovascular) Current Past N/A
Low Blood Pressure Current Past N/A
Hypoglycemia (Low Blood Sugar) Current Past N/A
Diabetes: TYPE I / TYPE 2
Current Past N/A
Tinnitus (Ringing in Ears)
Current Past N/A
Difficulty Taking Deep Breath / S.O.B
Current Past N/A
Current Past N/A
Current Past N/A
Current Past N/A
CFS (Chronic Fatigue Syndrome) Current Past N/A
Addison's Disease / Congenital Adrenal
Hyperplasia
Current Past N/A
High Cholesterol Current Past N/A
Current Past N/A
Low Steroids / Low Cortisol Current Past N/A
ADD / ADHD / Autism
Current Past N/A
Pancreas
Adrenals (Glandular System)
0
4
Updated Jan. 2021
Are You Currently Pregnant? Yes No
Are You Currently Breastfeeding? Yes No
Irregular Menses (Also Pituitary) Current Past N/A
Excessive Bleeding During Menstruation Current Past N/A
Ovarian Cysts / Fibroids
Current Past N/A
Endometriosis / Atypical Cells
Current Past N/A
Fibrocystic Breasts Current Past N/A
Current Past N/A
Low / Excessive Sex Drive
Current Past N/A
Have You Had a: Complete Hysterectomy /
Partial Hysterectomy
Current Past N/A
Difficulty Conceiving Current Past N/A
Birth Control Pills? For How Long:
Current Past N/A
Do You Have Prostatitis?
How Often do You Urinate?
Current
Past
N/A
Have You Been Diagnosed With Prostate 'Cancer'?
Current Past N/A
What are Your PSA's? Current Past N/A
Testicular Hypertrophy (Enlarged Testicles) Current Past N/A
Low / Excessive Sex Drive
Current Past N/A
Erection Problems Current Past N/A
Premature Ejaculation Current Past N/A
Bowel Movements per Day:
0
2
3
4+
Crohn's
/ Colitis / Gastritis / Enteritis /
Diverticulitis
Current Past N/A
Gastroparesis (Paralysis of the Stomach) Current Past N/A
Hiatus Hernia Current Past N/A
Coated Tongue, Especially Upon Waking: (white,
yellow, green, brown)
Current Past N/A
Diarrhea / Constipation
Current Past N/A
Stomach / Intestinal Ulcers
Current Past N/A
Current Past N/A
Gas Problems (Also Pancreas) Current Past N/A
Other GI Issues Not Listed:
Current Past N/A
Gastro-Intestinal Tract
Females Only
Males Only
5
Updated Jan. 2021
1
Difficulty Digesting Fats Current Past N/A
Fats or Dairy Cause Stomach: Bloat / Pain
Current Past N/A
Light Colored or White Stools Current Past N/A
Pain Mid-Back (Especially After Eating) Current Past N/A
'Liver' or Brown Spots (Not Freckles) Current Past N/A
Current Past N/A
Jaundice of: Eyes / Skin
Current Past N/A
Anemia Current Past N/A
Hepatitis A, B, or C
Current Past N/A
Alcohol Consumption:
Don't Drink
Daily Weekly Monthly or Less
Angina / Chest Pain Current Past N/A
Myocardial Infarction (Heart Attack) Current Past N/A
Pacemaker / Stents / Other Open
Heart Surgery
Current Past N/A
Do You Feel Pressure on Your Chest? Current Past N/A
Current Past N/A
Blemishes / Rashes / Acne
Current Past N/A
Dermatitis / Eczema / Psoriasis
Current Past N/A
Dry, Itchy Skin Current Past N/A
Excessively Oily Skin Current Past N/A
Dandruff Current Past N/A
Any Other Skin Problems: Please List:
Current Past N/A
Do You Have Any Tattoos? Yes No
Cardiovascular
Skin
Liver/ Gallbladder / Blood
6
Updated Jan. 2021
Hair Loss / Balding / Fully Bald (not by
choice)
Current Past N/A
Have You Ever Had Any Lymph Nodes Removed? Yes No
N/A
N/A
Swollen Lymph Nodes / Lymphedema
Current Past N/A
Do You Have Edema (Fluid Retention)? Please Provide
Location(s):
Current Past N/A
Fibromyalgia / Scleroderma
Current Past N/A
Cold & Flu-like Symptoms Current Past N/A
Sore Throat /
Sinus Problems
Current Past N/A
Poor Memory / Brain Fog Current Past N/A
Blurred Vision Current Past N/A
Mucus in Eyes Upon Waking Current Past N/A
Current Past N/A
Other Type of Non-Malignant Mass / Tumor: Fatty Benign N/A
N/A
AIDS / HIV +
Current Past N/A
Low Platelet Count (Also Cardiovascular) Current Past N/A
Appendicitis / Appendectomy
Current Past N/A
N/A
N/A
Boils /
Pimples / Cysts / Abscesses
Current Past N/A
Gout Current Past N/A
Toxemia / Cellulitis
Current Past N/A
Sleep Apnea Current Past N/A
Do You Snore? Current Past N/A
How Many Were Removed?
Location of Non-Malignant Mass / Tumor:
Date of Appendicitis / Appendectomy:
Date of Tonsillectomy (Tonsils Removed):
Lymphatic System
7
Updated Jan. 2021
UTI / Bladder Infection / Cystitis
Current Past N/A
Burning While Urinating Current Past N/A
Weak Bladder / Urinary Incontinence
Current Past N/A
Restricted Urine Flow Current Past N/A
Kidney Stones Current Past N/A
Nephritis Current Past N/A
Cramping or Pain Mid-to Lower Back on Either Side
Current Past N/A
Lower Back Weakness / Lack of Strength Current Past N/A
Sciatica Current Past N/A
Bags Under Eyes Current Past N/A
Bronchitis / Asthma / COPD /
Emphysema / Pneumonia
Current Past N/A
Pain / Difficulty Breathing Current Past N/A
Current Past N/A
Collapsed Lung: Right or Left
Current Past N/A
Frequent Cough Current Past N/A
Color of Mucus Expectorated: Clear / Yellow /
Green / Brown / Black
Current Past N/A
Do You Use a : Nebulizer / Inhaler
Current Past N/A
Don't Know
Have You Been Diagnosed With Lung 'Cancer'?
Current Past N/A
Are You a Smoker? Current Past
Never Smoked
How Much do You Smoke?
Packs/Day:
or
Cigarettes/ Day:
Exposure to: Nuclear Wastes / By-Products
of Nuclear Wastes / Heavy Metals / Toxic
Chemicals
Current Past N/A
Current Past N/A
Have You Gone Through Chemotherapy or Radiation?
Current Past N/A
Have You Received the "Standard" Vaccinations?
Yes No
Yes No
Have You Received a Flu Shot?
Yes No
Current Past N/A
Please List Any 'Recreational' Drugs You Have Used:
Environmental and Other Toxic
Exposure
Respiratory System
What is Your Oxygen Saturation (or SP02)?
How Many Treatments of Chemo or Radiation?
Kidneys & Bladder
8
Updated Jan. 2021
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Completed 21 January 2022

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