Heart_nerve Questionnaire

The fields denoted with * are compulsory fields

* Name & Surname
* Telephone
* Email
For each statement that applies to you, enter a ' X '.

1.
Low back pain (now, or frequent)?
2.
Diabetes?
3.
Bone loss (Diagnosed with osteoporosis, osteopenia, brittle bones)?
4.
Anemic? (Low hemoglobin on lab test?)
5.
High blood pressure?
6.
Diagnosed with heart concerns, e.g. pulmonary heart disease?
7.
Congested arteries in the legs, varicose veins in legs?
8.
Kidney stones, now or in past?
9.
Nephritis, history of?
10.
Protein in urine (per urinalysis, dip stick)
11.
Sexual dysfunction (men and women)?
12.
Low libido [sex drive-men (impotency) and women (infertility]?
13.
Self confidence is low?
14.
Back of knees are often sore, achy, or weak?
15.
Lack of motivation, apathy?
16.
Easily discouraged?
17.
Swelling of ankles and/or feet?
18.
Swelling and dark 'shadows' under eyes?
19.
Tinnitus, ringing in ears?
20.
Flashes of heat, "steaming heat inside" sensation?
21.
White, foamy urine?
22.
Many fears, phobias?