This Free Health Screening is your place for an expert professional opinion on your health matters.

Free Natural Health Screening Form

Video Link MP4 Version

This free health screening is a professional level screening that qualifies you to purchase the two books on the Pain Relief Diet. When you have completed this form you will be given instructions on how to obtain the books. We also offer you a free 15 minute meet the doctor consultation all designed to help you along the roadway to the Pain Relief Lifestyle and Optimal Health Secrets.

Please Note: The Free Screening is a mini screening. For a much more thorough health and pain assessment, take the Canadian Holistic Online Consultation and keep in mind that this online consultation is not designed to assess recreational or hard drug usage. For help with those issues we recommend you see a licenced health care provider specialising in that field.

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* CodeName:

* Email Address:

* Retype Email Address:

* LIA Agent Number: (If you do not have a LIA Agent then just leave the (A1A). )

* How did you find out about our web site? (Who, or what web site, referred you to our web site?)

Optional: Please leave your phone number in the format: 000-000-0000

PhoneNumber:

Your Age:

Female
Male

Please don't guess at these following measurements. If you have not checked them recently then re measure now please.

Weight

Height

Measure your waist circumference at the NARROWEST point, and your hip circumference at the LARGEST point.

Waist Circumference (narrowest point)

HipCircumference (widest point)

Pain Severity Assessment Scale

Indicate the severity of your major pain, from zero to ten, with ten being the most severe.

My pain severity is about:

0 No Pain
1
2
3
4
5
6
7
8
9
10 Excruciatingly severe Pain

Food Reaction Test

Check off the items below of everything that applies to you right now today.

Low Back hurts when lying flat on the back or on the stomach when there has been no injury.
You wake up with LOW BACK pain even though you are relaxed and there has been no injury.
You wake up with NECK PAIN even though you are relaxed and there has been no injury.
Some nights in bed, the pain is worse; some nights it is better for no known reason.
A joint that has intermittent pain is painful now.(Someone has said it is arthritis.)
A joint that is normally not painful now aches, but only a little.
Sharp fast pains (3-10 seconds in duration) come and go in unusual locations for no apparent reason.
Your abdomen is tender in places when pressing on it.
The abdomen aches a little now and then, even when not pressing on it. This ache may travel from one side of the abdomen to the other.
The nose is plugged up, runny, or stuffy, more than the day before, but you have no cold or flu.
You don't feel alert but feel as though you are in a fog with cloudy thinking and inability to concentrate. (This is often a key sign of a food problem.)
You have loose bowel movements but do not have the flu.
You have constipated bowel movements. (Firm, hard, and difficult to pass without straining.)
You have haemorrhoids, blood in the stools, or blood on toilet tissue.
In the morning upon awakening, your fingers feel swollen or tight when making a fist. (No one can tell you what causes this.)
Your skin comes up with wide red areas when scratching or rubbing an itch.
There is increased itching of the skin in many unusual locations.
You have many tender points on your body that hurt when pressed on.
You have more tiredness or fatigue in the morning upon awakening than usual, but there's no reason for it. (There has been no late-night loss of sleep, alcohol intake, or medications.)
You are tired or fatigued during the day even though you slept a lot the night before.

Bowel Transit Time

To calculate your BOWEL TRANSIT TIME, eat a large handful of sunflower seeds with a large meal of the day, but do not chew them very well. You want to leave the cellulose layer around the seed. Mark down the time that you take them. (You can also use corn.)

Now watch your bowel movements and when you see the kernels of sunflower seeds, or corn, mark this time down as well.

Calculate the time interval in hours between those two times and that is your Bowel Transit Time. Write it down somewhere please.

Bowel Transit Time (In hours)(NOTE: If you don't know your Bowel Transit Time then select 24.)

Nutritional Supplementation

Record your present vitamin, mineral, and other supplement intake. List all of the vitamins, minerals, and other supplements of all kinds of that you consume. Include the manufacturer’s name. Write this on a piece of paper so you can enter it into the computer, or on the alternative, bring the bag of supplements to your computer, read the labels and enter that data into the proper place on the Pain Assessment page of the PRLStore.com web site.

Bottle or package label name and Manufacturer

Amount of Ingredients
List every ingredient in the product please, and we need the amounts.
1.
2.
3.

My nutrition supplementations are:
If you are not taking any then type in 'None'.

Ten Lifestyle Questions

1. Are you familiar with the Five Pillars of Optimal Health Secrets?
No Yes

2. Do you do something regularly to help your spinal health?
No Yes

3. Do you pay attention EVERY DAY, to healthy eating practices?
No Yes

4. Do you practice some kind of fitness program REGULARLY (3-4 times a week) every week?
No Yes

5. Do you know what a well designed fitness program should entail?
No Yes

6. Do you take alcohol on a daily basis? (Alcohol is a stressor to physiological systems.)
Yes No

7. Do you take recreational drugs? (Drugs are a stressor to physiological systems.)
No Yes

8. Are you overweight?
Yes No

9. Are you on a weight loss diet of some kind?
No Yes

10. Are you happy with your life so far?
No Yes

Would you like us to contact you by phone to discuss this Screening?
Yes No

Please leave your phone number in the format: 000-000-0000

PhoneNumber:

Please indicate when we should try to contact you.

Preferred Time

Preferred Date:

Comment

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