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Email: Phone: (419) 420-1555 Fax: (419) 420-1556 NUTRITIONAL EVALUATION
Tests Used for Analysis:
Patient Symptom Survey.
Patient's comments:
My concerns are fatigue and hair loss.
This analysis and the recommendations are not for the purpose of treating or curing disease (cancer, hepatitis, arthritis, diabetes, M.S., heart disease, etc). The purpose for this nutrition and lifestyle program is to create an optimum environment in which your body can heal and repair itself. This is achieved by eliminating foods and toxins, which adversely affect the body, and by providing nutrients that the body may Primary Findings Suggestive of:
Hyperlipidemia; Gastro/Intestinal dysfunction; Noted Blood Values; High Hair Aluminum; High Hair Lead; Medications:
Glucophage - 6 months - 2 years.; Hydrochlorothiazide - More than 2 years.; Lipitor - More than 2 years.; Side Effects of Medications:
Glucophage (for diabetics) diarrhea; nausea; vomiting; abdominal bloating; flatulence; anorexia; unpleasant Nutrients Depleted: Folic Acid, Vitamin B12 Uses: Hydrochlorothiazide is a "water pill" (diuretic) that increases the amount of urine you make, which causes your body to get rid of excess water. This drug is used to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems. This medication also reduces swelling / fluid retention (edema) which can result from conditions such as congestive heart failure, liver disease, or kidney disease. This can help to improve symptoms such as trouble breathing. Additional Uses: This medication may also be used for a condition known as "water diabetes" (diabetes insipidus) and to help prevent calcium kidney stones.
Side Effects: Dizziness, lightheadedness, headache, blurred vision, loss of appetite, stomach upset, diarrhea, or constipation may occur as your body adjusts to the medication. If any of these effects persist or worsen, notify your doctor or pharmacist promptly. This medication may lead to excessive loss of body water and minerals (including potassium). Tell your doctor immediately if you have any of these unlikely but serious symptoms of dehydration or mineral loss: muscle cramps or weakness, confusion, severe dizziness, unusual dry mouth or thirst, nausea or vomiting, fast/irregular heartbeat, unusual decrease in the amount of urine, fainting, seizures. Tell your doctor immediately if any of these unlikely but serious side effects occur: numbness/tingling of the arms/legs, decreased sexual ability. Tell your doctor immediately if any of these highly unlikely but very serious side effects occur: persistent sore throat or fever, easy bleeding or bruising, stomach/abdominal pain, persistent nausea/vomiting, yellowing of eyes/skin. A serious allergic reaction to this drug is unlikely, but one should seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction include: rash, itching, swelling, severe dizziness, trouble Nutrients Depleted: Coenzyme Q10, Magnesium, Phosphorous, Potassium, Sodium, and Zinc. Lipitor (lipid or cholesterol lowering drug) causes liver dysfunction; SGOT and SGPT three times the upper limit of normal is considered normal; CPK values greater than 10 times the normal limit is considered normal. Adrenal failure, diffused muscle pain, muscle tenderness, weakness, malaise, fever, myopathy or muscle disease if used with certain other drugs (these drugs include: antacid (Maylox), dioxin, erythromycin, and oral contraceptives). Long term use in laboratory studies of two years indicated an increase in liver cancer. Should not be used in pregnant women. Other adverse reactions include: edema (part or whole of the body), digestive problems, gastritis, colitis, vomiting, ulcers, bleeding gums, bleeding ulcers, hepatitis, pancreatitis, gall bladder disease, asthma, decreased libido, leg cramps, bursitis, itching, alopecia, dry skin, acne, cystitis, hemoturia, kidney stone, breast tenderness, various hemorrhage, loss of taste, palpitations, Prozac (AKA Sarafem) (used for depression) autonomic instability; extreme agitation; delirium; rash and itching; fever; arthritis; edema; lymph adenopathy; proteinuria; elevated liver enzymes; possible lung, kidney, or liver involvement; anxiety; nervousness; insomnia; fatigue; tremors; sweating; gastrointestinal complaints; anorexia; dizziness; light headedness; dry mouth.
Interpreting Blood Lab Results
On the right hand side of your blood test results found later in this report, you'll see there is a Healthy Range and a Clinical Range. This Healthy Range is a more narrow range than the Clinical Range. Any test value outside of the Healthy Range indicates that it is not as good as it should be or it may be a sign of a developing condition that isn't bad enough to need medical treatment at this point. These test values that are outside of the Healthy Range are highlighted in yellow. The Clinical Range is a much broader range and is what the medical community uses. Any test value outside of the Clinical Range indicates a disease process. Test values "low" or "high" outside of the Clinical Range are highlighted in red. Test values that are "very low" or "very high" outside of the Clinical Range are highlighted in blue.
Interpreting Hair Lab Results
The measurement of hair element levels is a screening test for physiological excess, deficiency, or maldistribution. Hair element analysis is not a diagnostic test of element function, and hair element levels (either high or low) are not always indicative of pathology. This is because hair levels of some elements can be influenced by many factors such as shampoo, swimming pool and spa water and hair treatments. Because of pollution, industry, and other environmental factors, there is no way you can totally eliminate your exposure to some of these toxic elements. However, there are things we can do daily to limit or reduce our exposure to these toxic elements and therefore lessening the total toxic burden on your body. For each elevated toxic element the most common sources of exposure are highlighted.
Coronary Risk Assessment
The coronary risk is determined by taking the total cholesterol and dividing it by the HDL. To reduce your risk of cardiovascular problems a value below 4 is recommended. The Total Cholesterol is determined by adding the HDL, LDL, and VLDL together. Recent studies have shown a correlation between a high HDL and longevity. Think of HDL as the Healthy cholesterol and generally the higher the better. LDL is the bad cholesterol, as it tends to plug the arteries. The VLDL is the Very worst cholesterol and is more like sludge. Lower is better for the LDL and VLDL in determining coronary risk and overall health. Hyperlipidemia
Hyperlipidemia is basically too much fat in the blood. The Cholesterol and LDL Cholesterol are high and
the Triglycerides, HDL Cholesterol and VLDL Cholesterol are a little high. Poor diet, excess weight, caffeine intake and lack of exercise are usually the main cause for these findings.
Gastro/Intestinal dysfunction
The Blood Urea Nitrogen (BUN), BUN/Creatinine Ratio and Globulin are a little low and the A/G Ratio is
a little high. This is probably poor digestion and digestion problems and/or a low protein/high carbohydrate diet. A tendancy for edema and fluid retention is increased. Many drugs or medications can cause or contribute toward these findings. Digestive enzymes may be of benefit. Globulin, a type of protein, is important for the immune system and to fight disease. One out of every four bites of food you eat (25%) should be of a protein source, preferably more plant based protein such as seeds, nuts, beans and sprouts. Eggs and even some fish, chicken, turkey and possibly small amounts of red meat may be beneficial.
Glucophage; Lipitor; Prozac; Hydrochlorothiazide Nutrients:
Noted Blood Values
The LDH is a little high and this is associated with destruction of cells. This doesn't tell where or how, only
that too much destruction is occurring. The body is continually breaking down and rebuilding. The problem is when the breakdown is too much or the body isn't repairing quickly enough.
The Basophils are a little high and probably indicate a mild inflammatory reaction.
The Triglyceride/HDL Cholesterol Ratio is optimal. Recent studies have shown that the ratio of triglycerides to HDL was the strongest predictor of a heart attack. High triglycerides with low HDL levels increase levels of clotting factors in the bloodstream, which is unhealthy in protecting against heart disease. In adults, the triglyceride/HDL ratio should be below 2.
High Hair Aluminum
You have an aluminum level that is high. Any aluminum is too much. Aluminum toxicity is associated with
Alzheimer's and Parkinson's disease. Aluminum is, also, a heavy metal that displaces your other good minerals. One of the things that you should do to help your overall long-term health is to reduce your aluminum intake. The most common sources of aluminum are: anti-perspirants, aluminum
cookware, antacids, some baking sodas, baking powder, some breath mints, some skin lotion,
some cosmetics, aluminum foil, canned goods, emulsifiers in some processed cheese, table salt -
anti-caking compound, bleaching agent used in white flour, buffered aspirin, some toothpaste,
dental amalgams, cigarette filters, and drinking water (tap water). Do not eat or drink anything
that comes in a can. Read your labels before you purchase. I've even seen aluminum in a granola
Aluminum rods are commonly used in hot water tanks in area of acidic water. These rods will dissolve neutralizing the water, thus protecting the hot water tank. A rod of magnesium is an option for the same Note: Fluoride and Fluoridation increases the absorption of Aluminum.
Chlorella and Magnesium with Malic Acid have been reported to be quite effective in lowering Aluminum.
High Hair Lead
The Lead value is high in the hair.
The Center for Disease Control (CDC) reports the following symptoms as those frequently seen in exposed children: Abdominal pain, colics, severe and repeated vomiting; Irritability; Hyperactivity; Anorexia; Loss of appetite; Ataxia; Mental disturbances. Advanced stage: Mental retardation; Learning disability; Speech disturbances; Stupor or fatigue; Intermittent fever; Dehydration; Constipation, Diarrhea, Nausea; Altered sleep; Epileptic seizures; Headaches; Poor memory; Inability to concentrate; ADD/ADHD; Aberrant behavior; Decreased coordination; Irritability; Pain in abdomen, bones and muscles; Gout; Anemia.
Physiologically, the renal, nervous, reproductive, endocrine, immune, and hemopoietic systems are affected. Sub-toxic oral exposure to lead and cadmium increases the susceptibility to bacterial and viral infections.
Other symptoms associated with the early stages of lead intoxication are: Headaches; Vertigo; Tremor; Joint pain; Neuritis; General mental symptoms, psychoneuroses Symptoms of acute intoxication include: Colic; Loss of muscle strength; Muscle tenderness; Paresthesia; Signs of neuropathy. Lead is known to damage the kidney, the liver, and the reproductive system, as well as to interfere with bone marrow function, basic cellular processes and brain functions. It is known to be responsible for convulsions, abdominal pain, paralysis, temporary blindness, extreme pallor, loss of weight and appetite, constipation and numerous other problems.
Lead causes nerve and mental problems, especially affecting learning ability in children. It was reported that the IQs of middle-class children dropped five to seven points after lead exposure, and Moon, et. al., demonstrated that lead levels also related to decreased visual and motor performance.
Therapeutic considerations: Mild lead exposure can be treated successfully with oral chelating agents, targeted mineral therapy and dietary measures. The following should be considered: Lead displaced calcium. In the case of calcium deficiency, lead is more readily deposited in tissues. Increases in phosphorus intake, vitamin C, vitamin B-complex, pectin, Vitamin E, Vitamins A and C, and Chromium can avoid cellular damage and reduce lead levels; Inadequate vitamin D intake facilitates the absorption of COMMON SOURCES OF LEAD:
lead based paints; older homes; crystal; ceramics; canned food; food crops; water
Calcium MCHC; Chlorella; Hypo B-50; Spectramin Chelate; Vitamin C Noted Hair Values
Sodium (Na) is an essential element. Blood testing for Sodium and electrolyte levels is much more diagnostic and indicative of status. High Hair Sodium may be the result of an electrolyte imbalance, or possibly adrenocortical hyperactivity. In this condition, Blood Sodium is elevated while potassium is low. Potassium is elevated (wasted) in the urine. High levels of Sodium and Potassium in the hair are commonly high in association with elevated levels of toxic elements or xenobiotics. Elevated Sodium and Potassium levels are frequently concomitant with low levels of Calcium and Magnesium in hair.
Hair is a good indicator of uranium exposure. Blood and urine have been noted as NOT being representative of the body burden since the blood is rapidly cleared of uranium. Most forms of uranium are poorly absorbed by the body with the exception of the lungs, which absorb airborne uranium readily. Uranium forms many complexes with proteins and bone and can substitute for calcium. It is deposited throughout the body and chronic fatigue is often reported in association with high hair levels. Published data correlates Uranium exposure, nephrotoxicity and all forms of cancer. Kidney and bone are the primary sites of Uranium accumulation. Uranium has been noted to be higher in female hair than males living in the Uranium is considered to be a toxic element, although its toxic effects are not well known. It is a moderately common element with three isotopes. U238, the most common isotope, represents over 99% of the naturally occurring element. It is the only isotope of concern in this analysis. It is reasonably stable with a low level of radioactivity and a half life of 4.5 billion years. Uranium is used in glass
manufacturing, ceramics, colored glass, high phosphate fertilizers and in some chemicals.
Drinking water is a significant source of U238 in many regions. Radon can be a by-product of
U238 decomposition.
The Hair Chromium is high. This has been seen in patients with allergic dermatitis, skin ulcers, bronchitis, lung cancer, cerebral thrombosis, and cerebral hemorrhaging, and has been reported to lead to insomnia and an increase in unpleasant dream activity. Elevated levels of chromium have been detected in the hair of children with psychotic and neurotic behavior, and in the hair of children with learning disabilities when compared to controls. Sources of exposure include stainless steel manufacturing, wood finishing, leather The Hair Molybdenum is low. Molybdenum is essential for plants. Medical research states that it is possibly anticarcinogenic. The states of Colorado and Ohio have soils particularly rich in Molybdenum, and report the lowest incidences of cancer of the esophagus. This type of cancer is particularly widespread in South Africa, which has very low Molybdenum concentration. Molybdenum is important for uric acid metabolism. Liver and kidney are good meat sources. Good plant sources are legumes, wheat germ, and Molybdenum deficiency: reduced resistance against cancer, impotence, uric acid accumulation (gout), defects in the metabolism of sulfur amino acids, dental caries, susceptibility to asthma.
The Hair Selenium is low. Selenium is found in the liver, red blood cells, platelets and other tissues. It is a strong antioxidant that works with vitamin E. It is an antioxidant that helps prevent chromosomal damage and protects cellular function. A deficiency has been associated with many types of cancers and tumors. In animals a deficiency of selenium can lead to brain dysfunction, cardiovascular, liver and muscle problems and can affect fetal development. Statistically, the occurrence of cancer is considerably higher in areas with a low selenium content of the soil. It also counteracts the effects of chemical allergies and sensitivities.
Barium compounds are found in soaps, ceramics, paper, glass, plastics, textiles, dyes, feul additives, rubber, paint and pesticides. Barium toxicity can cause vomiting, diarrhea, abdominal pain, muscular and myocardial stimulation, tingling in the extremities, and loss of tendon reflexes.
The Germanium levels in the Hair are low. Animal studies have shown germanium to have significant The Zirconium levels in the Hair were high. This has not been proven to be clinically significant.
The Arsenic level is a little high. Chronic arsenic exposure is known to cause: Bone marrow depression; Leukopenia; Normochromic anemia; Exfoliation and pigmentation of skin; Neurological symptoms; Polyneuritis; Altered hematopoiesis; Liver degeneration; Kidney degeneration; Skin cancer; Cancers of the respiratory tract, agitation, learning impairment, and confusion. Delayed toxicity symptoms include abdominal pain, nausea, vomiting, hematuria, and jaundice. Ingestion of relatively large amounts of soluble arsenic compounds, especially on an empty stomach, affect the myocardium, causing death within a few hours. Ingesting smaller amounts of arsenic can cause epigastric pain, vomiting and diarrhea, followed by inflammation of the conjunctiva and respiratory mucous membranes, epitaxis, transient jaundice, cardiomyopathy, erythematous or visceral rashes, and sweating. Other symptoms: malaise; muscle weakness; eczema; dermatitis; increased salivation; strong "garlic breath", alopecia totalis, vomiting, diarrhea and skin cancer. Hematological, renal, or pancreatic dysfunction may be observed. Symptoms of neuropathy are experienced typically appear as with tingling and paresthesia in the extremities. Proteinuria and methemoglobinemia are frequently observed, causing renal failure and death. Arsenic can be absorbed by the human body through the respiratory and gastrointestinal tracts and through the skin. Arsenic is found in tobacco smoke and is a suspected causative factor in lung cancer. Metal
smelting and the production of glass, ceramics, insecticides, fungicides and herbicides mobilize
environmental arsenic. Drinking water may also be a source of arsenic, and the use of
arsenic-containing paints is a known source of arsenic poisoning. Elevated hair levels are seen long
before acute clinical signs of arsenic toxicity are obvious.
Therapeutic consideration for Chronic overexposure: Antioxidant therapy, especially ascorbic acid or calcium ascorbate, vitamin E (all tocopherols), increased intake of sulfur-containing amino acids, vitamin B6. Note: Arsenic suppresses iodine and selenium. Research: The relationship between cognitive functions and hair mineral concentrations of lead, arsenic, cadmium, and aluminum was examined for a random selection of 69 children. The data obtained showed a significant correlation between reading and writing skill and elevated arsenic levels, as well as interaction between arsenic and lead. Children with reduced visual-motor skills, had clearly elevated aluminum and The Mercury (Hg) level is a little high and Mercury is a toxic element for humans and animals. Hair mercury level is an accurate indicator of mercury body burden. A considerable variance in the sensitivity of different individuals to mercury has been observed, with some exhibiting symptoms at 3 to 5 ppm. Even very low levels of mercury have been found to suppress biological selenium activity. After dental amalgams are used, elevated hair mercury may be observed for six months to over a year. Hair mercury has been found to correlate with acute myocardial infarction where on average a 1 ppm mercury was found to correlate with a 9 percent increase in acute myocardial infarction risk. Mercury displaces Selenium (which is a major anti-oxidant), zinc (protein, DNA and energy metabolism) and copper. Supplementation of magnesium, zinc, calcium, selenium, and manganese has been shown to be beneficial in relieving mercury loads.
Symptoms of acute contamination: Metallic taste, thirst, discoloration and edema of oral mucosa, burning mouth pain, salivation, abdominal pain, vomiting, bloody diarrhea, severe gastroenteritis, colitis, nephrosis, Symptoms of chronic contamination: gingivitis, weakness, ataxia, intention tremors, Chronic fatigue (caused by inhibition of thyroid conversion of T4 to T3); depression; poor memory and cognitive function; learning disabilities; behavioral disorders; emotional instability; speech impairment, irritability; peripheral numbness, tingling or neuropathy; sleep disturbance; decreased senses of touch, hearing or vision; hypersensitivity and allergies; persistent infections including chronic yeast overgrowth; compromised immune function; cardiovascular disease. It disrupts intracellular transport in neurons and can decrease the production of neurotransmitters. Eventually this can lead to autoimmune diseases such as SLE (systemic lupus erythematosis), myelinopathies such as MS and myasthenia gravis, rheumatoid arthritis, MCS (multiple chemical sensitivity), and chronic candidiasis. An inverse relationship has been observed between hair mercury levels and intelligence scores in elementary school children. Other sources of mercury are: large fish, pesticide residues, mercurial fungicides on seed grains,
dental fillings, coal burning, calomel (mercurous chloride), interior paints, pharmaceuticals, the
manufacture of paper, pulp and plastic products, and water.
The Potassium is a little high and is not necessarily reflective of dietary intake or nutrient status. However, elevated Potassium may indicate adrenocortical insufficiency or it may be reflective of metabolic disorders associated with exposure to potentially toxic elements and toxic heavy metals. Elevated Potassium may reflect overall retention by the body or maldistribution of this element. Hair is occasionally contaminated Nutrients:
Calcium MCHC; Chlorella; Germanium; Multiple; Spectramin Chelate To help get these heavy metals out of your system, which is very important, Chlorella is recommended. Magnesium and selenium, are both very important in getting these toxic metals through the kidneys. Chlorella and cilantro have the unique ability to actually get these heavy metals out of brain, liver, heart, and lung tissue. Adding fresh cilantro to the diet is also recommended. Cilantro is an herb that can be found in most supermarkets. Chop it up and add it to salads, sauces, etc. Since we are constantly being exposed to heavy metals in our society, it is recommend that even after you are feeling better that you continue with the Lifestyle / Dietary Recommendations:
Below is a list of foods and items that we strongly recommend you avoid. READ YOUR INGREDIENT LABELS!! Later in the report, you will find exchanges for these foods and helpful hints on implementing 1. Artificial Sweeteners: aspartame, saccharin, sucralose, xylitol, sorbital, malitol, etc.
2. Processed Meats: "nitrate" or "nitrite" foods: pork products; bologna; wieners; any luncheon meat with 3. MSG (monosodium glutamate): found in many dressings, sauces and Chinese foods. HVP (hydrolyzed vegetable protein) can contain up to 40% MSG.
6. Fried Foods: deep fried, breaded foods 7. Artificial Fats: "hydrogenated" fats [a.k.a. "trans fat"] are found in margarine, most pre-packaged foods and dressings; "interesterified" fats; "Olestra" products, etc.
8. Refined Carbohydrates: processed foods such as white sugar, white flour, "unbleached or unbrominated" foods, corn syrup, "enriched" foods, etc.
9. Preservatives, additives, sulfites, artificial colors, FD&C colors and dyes 10. Commercial Meats: Try to get the cleanest, freshest meat you can find. Look for meat that is labeled with terms such as "No Hormones", "No Steroids", "No Antibiotics", etc.
11. Shellfish and Bottom-dwellers: crab, shrimp, lobster, oyster, catfish, etc.
12. Dairy Products: cottage cheese, yogurt, cheese, butter, sour cream, etc. (anything with cow's milk). This 13. Coffee (regular & chemically decaffed), Liquor (distilled), All sodas, Tea (black decaf & black regular) 14. Soy Products: isolated soy protein, texturized vegetable protein, soy supplements, soy protein powder, soy protein bars, tofu, etc. Limited fermented soy products (tempeh and miso) and whole soy beans are acceptable. Don't make soy your main protein source, limit to 3-4 servings per week.
15. Chlorine and Fluoride Sources: tap water, heavy chlorine exposure in swimming pools, fluoride toothpaste, fluoride supplements, fluoride mouthwash, etc.
Aerobic Exercise [i.e. jogging, cycling, fast-paced walking, etc]: It is recommended that you build up to at least 40 minutes a day. If at first you do not have the energy to exercise this much, it is recommended that you start slowly by exercising 10 minutes two or three times a day until you can gradually build up to 40 Strength Training: If you are not currently on a weight training program, a muscle building exercise (i.e. step exercise) 10 minutes a day is encouraged. If at first you do not have the energy or physical ability to perform this exercise, it is recommended that you start slowly by setting a goal to do this exercise 2 minutes two or three times a day until you can gradually build up to 10 minutes a day. Water Consumption: Drink 1 quart of clean, filtered water per 50lbs of body weight per day. We recommend using "reverse osmosis" filtration for your drinking and cooking water. Reverse Osmosis is a type of filtration that gets the water the cleanest that technology has to offer without robbing the water of all essential minerals. Distilled water is not recommended. Since distilled water has little or no mineral content, it acts like a vacuum that can actually leach minerals from your system. If you are already mineral deficient, it will worsen the problem. Cooking foods in distilled water will pull the minerals from the food and lowers A word of caution - anytime you make drastic changes in diet, vitamin intake, or exercise, realize
that you may feel somewhat worse before you feel better. It doesn't happen often, but as your body
detoxifies, you may feel worse if it occurs too fast. If you do feel worse, don't panic, it will pass in probably 2-3 days. If this problem does occur, take half of what is recommended for three days and slowly over two weeks progress to taking the complete program.
Everything that has been recommended is very important and many of these things work together. In order to get the most effective results, it is important that you follow the program exactly as outlined. Following the diet may not be easy, but if you do, you will get the best outcome. Likewise, if you don't take the vitamins, or only take part of them, you may not see the expected results. Many people with some very serious problems have been helped using this program. The purpose of this analysis is to benefit you. This is for your well being, so please do the program as recommended so that you will achieve the best results.
Attached is a list of vitamins that have been carefully selected for your specific problems. These vitamins are recommended because they are of the highest quality. Occasionally, you will hear rumors regarding vitamin toxicity. Rest assured that these issues have been researched and the risk of significant side effects is extremely low. Historical data and experience have shown these vitamins, along with the dietary changes, to be the best in helping you achieve the necessary improvements needed on your test results. If for some reason you need to return the supplements, please contact our front desk for our returns policy.
Please keep this report for future reference and bring it with you to your next evaluation.
We will be happy to provide you with an extra copy or fax/send your report to any other doctors at your If we can be of any further assistance to you or your family please do not hesitate to ask.
Yours In Health,
Dr. Chris Berry
Test Description
Test Description
Toxic Elements
Essential Elements



from Alan Duff, Once were warriors . Auckland: Tandem, 1994, pp. 7–14. A Woman in Pine Block Bastard, she’d think, looking out her back kitchen window. Lucky white bastard, at that glimpse of two-storey house through its surround of big old trees and its oh so secure greater surround of rolling green pastureland, while she – Clicking her tongue, Oh to hell with him. Or good luck to

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Metabolic Assessment Form Name: ____________________________________________________ Age: ______ Sex: _____ Date: ______________ PART I Please list the 5 major health concerns in your order of importance: 1. _____________________________________________________________________________________________ 2. _____________________________________________________________________________

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