Health Assessment - Cornerstone Health Team

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Name *

First

Last

Email *

Phone Number *

Please check ALL that apply to you. One of our Health Educators will be in contact with you to help determine the BEST course of action.

Life Shake *

no energy/always tired muscle soreness difficulty concentrating hormonal imbalance/mood swings osteoporosis/low bone density low blood sugar menopausal symptoms thyroid problems inflammation premature aging want to prevent cancer digestive issues consume GMO/processed foods hair loss/thinning growing pains heart issues

Vitamin C *

I catch every virus around want to prevent cancer frequent infections bruise easily hang nails varicose/spider veins allergies/frequent colds swimmer's ear UTI/bladder infection smoker macular degeneration take oral contraceptives bleeding gums/nose iron deficiency

Herblax *

food intolerances i.e. lactose constipation diarrhea gas or bloating indigestion or heartburn feel ill after eating crohn's disease colitis or IBS gluten intolerance thrush canker sores fatigue foot odor consume GMO/processed foods <2 bowel movements daily

OsteoMatrix (calcium) *

muscle cramps/tension insomnia/sleep problems cavities/loss of tooth enamel joint pain/backaches weak fingernails headaches colon cancer history low dairy intake fibromyalgia restless legs

Zinc *

slow healing weak immune system poor skin health want to maintain prostrate health cataracts using estrogen therepy

Lecithin *

high cholesterol poor memory concentration problems learning challenges no gallbladder

Vita Lea *

<5-9 serving daily of fruits & veggies <6-11 serving daily of whole grains <2-3 servings daily of dairy eat out >2 per week stress, stress, and more stress want to prevent cancer want to prevent heart disease vegetarian or vegan thyroid concerns keep cholesterol in check exercise >3 times per week strenuous job bone health concerns smoker toxin exposure (cleaners, job related)

Vitamin D3 *

brittle nails autoimmune disorders work indoors diabetic SAD (seasonal mood disorder) PMS/infertility/menopause want to prevent cancer in cancer remission eczema/psoriasis consume GMO/processed foods depression

Vita-E Complex *

asthma poor circulation high blood pressure diabetes history of stroke autoimmune disoders cold hands and feet family history of cancer poor night vision high cholesterol

B Complex *

I'm tired all the time irritability crave sweets/caffeine headaches stress, stress, and more stress PMS rapid heartbeat/palpitations ridges in nails skin problems/hair loss carpel tunnel syndrome canker sores/ cold sores

Carotomax/Flavomax *

respiratory infections bronchitis or pneumonia viruses or weak immune system family history of cancer high risk of heart disease <5 servings of veggies/fruits eye disorders toxin exposure (cleaners, job related)

Iron Plus C Complex *

anemia heavy menstruation dark circles under eyes vegetarian diet low energy/fatigue/stress

GLA Complex *

PMS/menstrual irregularities skin eruptions/dryness/eczema fibrocystic disorders arthritic pain and swelling dry eye syndrome fertility problems menopausal symptoms

Alfalfa *

arthritis and joint pain sinus infections digestive problems kidney/bladder infections bad breath/body odor excess fluid retention allergies/asthma

Nutriferon *

repeated colds/infections/flu weak immune system allergies hepatitis C fibroid tumors

Optiflora System *

frequent antibiotic/med use ear & throat infections crohn's disease/colitis/IBS sensitivity to odors or scents rashes/skin issues recurring sinus infections vaginal/bladder infections/UTI foot fungus

Fiber Plan Drink/Tabs *

diabetes constipation frequent headaches/migraines acne colon problems diet high in processed foods heart disease

Garlic Complex *

blood clots/aneurysms viral/bacterial infections yeast infections/candida sinus infections colitis foot fungus

CoQ Heart (CoQ10 Enzyme) *

congestive heart failure fatigue/lack of energy cold hands/feet irregular heart beat or rhythm fluid retention/edema gum disease

Stress Relief Complex *

not enough hours in the day feel stressed out often time-pressure deadlines muscle tension angry outburst difficulty concentrating

Glucose Regulation Complex *

high blood sugar type II diabetic crave sweets, bread, pasta overweight high triglycerides low HDL >2 servings of caffeine a day

Gentle Sleep Complex *

insomnia TMJ/muscle tension headaches/anxiety rapid heartbeat

Shaklee 180 Inch-Loss System *

overweight difficult to lose weight trouble keeping weight off blood sugar issue "yo-yo" dieter

EZ-Gest *

food intolerences i.e. lactose gas or bloating indigestion or heartburn acid reflux no gallbladder consume GMO/processed foods

Omega-3 Complex *

high triglycerides high blood pressure poor circulation/blood clots migraine headaches ADD/ADHD autism/develepmental disorders eczema/psoriasis/dry skin ulcerative colitis bipolar disorder lupus/multiple sclerosis

Liver DTX Complex *

liver damage hepatitis cirrhosis take OTC prescription meds blurred/tunnel vision food allergies/intolerences dark circles/bags under eyes canker sores/acne candida/yeast overgrowth hives toxin exposure (cleaners, job related)

Menopause Balance Complex *

hot flashes sleep disturbances anxiety and mood swings short tempered depression/weepiness heart pounding while resting

Mindworks *

trouble concentrating vertigo/dizzy/ringing ears macular degeneration diabetic circulation problems cataracts. glaucoma dementia/Alzheimer's

Joint Health Complex *

osteoarthritis sports injuries decreased mobility cartilage degeneration

Saw Palmetto Complex (MEN) *

enlarged prostate gland slow/trouble urinating kidney/urinary infections

Vivix *

diabetes joint problems inflammation heart or circulation issues (including neuropathy) eye disorders/age spots brain health

Life Plan *

save Money convenience/time saving long term prevention consume GMO/processed foods

* This product is in the Life Plan

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All material provided on this website is provided for informational or educational purposes only, and is not intended as a substitute for the advice provided by your healthcare professional or physician.

© 2015-2017 Cornerstone Health Team. All Rights Reserved. team@cornerstonehealthteam.com

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