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You are here: Home > Step 2: Body Balance Questionnaire



The purpose of this questionnaire is to determine how Balanced or Imbalanced your body is. This includes not only the physical components but also the mental and emotional aspects as well. Although your total score is simply a “number,” it gives us valuable information in helping you to rebuild your health to an optimal level of wellness or simply to maintain your current status of well-being.

After you’ve finished the questionnaire, click on the level of therapy that corresponds to your total score and go to the optimum recommended treatment for you.

Please answer the following health questions. Once you have finished, total your scores at the bottom of each section and then again at the end of the questionnaire in order to evaluate your results.


Never or almost never have the symptoms 0

Occasionally have it, effect is not severe 1

Occasionally have it, effect is severe 2

Frequently have it, effect is not severe 3

Frequently have it, effect is severe 4

* These symptoms are indication of conditions that should be referred to medical professionals for evaluation if scores are 2-3 or 4.

Dental:

 

  1. Bad breath
    0 1 2 3 4

  2. Accumulate a lot of plaque and calculus
    0 1 2 3 4

  3. Gums bleed when you brush or floss your teeth
    0 1 2 3 4

  4. Frequent dental problems, i.e., decay or sensitive teeth
    0 1 2 3 4

  5. Saliva pH 6.5 or lower
    0 1 2 3 4

  6. Sugar Exposure
    0 1 2 3 4

Dental Picture

Total Dental:
Digestive System:

 

  1. Acid Reflex or Heartburn
    0 1 2 3 4

  2. Diarrhea
    0 1 2 3 4

  3. Constipation
    0 1 2 3 4

  4. Bloating or gas after eating
    0 1 2 3 4

  5. Infrequent bowel movements; 0 - 1 per day
    0 1 2 3 4

  6. Allergic or intolerance to certain foods
    0 1 2 3 4

Total Digestive System:

Metabolism:

 

  1. Obesity
    0 1 2 3 4

  2. Hypoglycemia
    0 1 2 3 4

  3. Feeling of coldness
    0 1 2 3 4

  4. Craving certain foods
    0 1 2 3 4

  5. Water Retention
    0 1 2 3 4

  6. Fatigue
    0 1 2 3 4

Total Metabolism:

Joints and Muscles:

 

  1. Muscle aches or joint aches
    0 1 2 3 4

  2. Gout
    0 1 2 3 4

  3. Arthritis
    0 1 2 3 4

  4. Fibromyalgia
    0 1 2 3 4

Total Joint and Muscles:

Skin:

 

  1. Skin Rashes
    0 1 2 3 4

  2. Eczema
    0 1 2 3 4

  3. Acne
    0 1 2 3 4

  4. Increased sweating, ear wax
    0 1 2 3 4

  5. Saliva pH 6.5 or lowerFever blisters
    0 1 2 3 4

  6. Brown spots on hands and face
    0 1 2 3 4

Total Skin:

Ear, Nose, and Throat

 

  1. Increased salivation
    0 1 2 3 4

  2. Mouth ulcers
    0 1 2 3 4

  3. Common cold
    0 1 2 3 4

  4. Sinusitis
    0 1 2 3 4

  5. Sore Throats
    0 1 2 3 4

  6. *Ear Infections
    0 1 2 3 4

  7. Hay Fever
    0 1 2 3 4

  8. Cough
    0 1 2 3 4

Total Ear, Nose, and Throat:

Kidneys:

 

  1. Increase in urination frequency and amount
    0 1 2 3 4

  2. Needing to get up in the night to pass urine
    0 1 2 3 4

  3. *Urinary tract infections
    0 1 2 3 4

  4. *Kidney stones
    0 1 2 3 4

  5. *Blood in the urine
    0 1 2 3 4

Total Kidneys:

Mind and Brain

 

  1. Hyperactivity
    0 1 2 3 4

  2. Stammering when speaking or problem finding words
    0 1 2 3 4

  3. Difficulty in concentration
    0 1 2 3 4

  4. *Sleep disturbance
    0 1 2 3 4

  5. Difficulty in making decisions
    0 1 2 3 4

  6. Headache
    0 1 2 3 4

  7. Poor memory
    0 1 2 3 4

  8. Poor coordination
    0 1 2 3 4

  9. *Compulsive behavior
    0 1 2 3 4

Total Mind and Brain:

Emotions

 

  1. Irritability
    0 1 2 3 4

  2. Nervousness
    0 1 2 3 4

  3. Mood swings
    0 1 2 3 4

  4. Frequency crying
    0 1 2 3 4

  5. Aggressive behavior, i.e., road rage
    0 1 2 3 4

  6. Anxiety
    0 1 2 3 4

  7. Fear
    0 1 2 3 4

  8. Confusion
    0 1 2 3 4

  9. *Depression
    0 1 2 3 4

Total Emotion:

TOTAL :


Please note, results are not saved after you navigate away from this page. 
Please print and save a copy of this questionnaire, then enter your responses in the Lifestyle Assessment booklet before starting your 90 Days to Better Health.
Once you've completed the program, fill out the Body Balance Questionnaire again to evaluate your progress.
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Results: