How do You Feel? Before/After

How Do You Feel Today?

Check This Side On Day 1

Starting Date __________                                          30 Days      45 Days      60 Days

  No Pep  
  Overweight / Underweight
  Splitting, Breaking Fingernails
  Dull, Thinning Hair
  Need Coffee, Tea, of Pop to Keep Going
  Headaches
  Great Desire for Chocolate, Sweets
  Constipation / Hemorrhoids
  Bleeding Gums
  Bruise Easily
  Take Aspirin / Tylenol Often
  Poor Digestion
  Poor Circulation / Cold Hands, Feet
  Hard To Wake Up / Get Up in the Morning
  Can’t Fall Asleep
  Dry / Oily Skin
  Complexion Problems
  Leg Cramps
  Bad Breath / Smelly Feet
  Subject to Colds & Infections
  Nervous or Depressed
  Various Aches & Pains
  Have Vague “Blah” Feeling
  Require Tranquilizers
  Use Antacids (Tums, Rolaids, etc)
  Shortness of Breath
  Under Stress
  High Cholesterol / Triglycerides
  Sinus & Allergy Problems
  Backaches
  Joint Stiffness
  Water Retention
  Menstrual Cramps / PMS
  Hot Flashes
  Family History: Cancer Heart Stroke Diabetes Other You cannot eliminate this, but you can manage it with nutrition.

This form is mostly for your eyes only.  Many times we don’t even realize that things are getting better, until we take the time to evaluate how we feel.

To print this form you can print this page directly from your navigation menu, or you can copy and paste onto a word document and print from there.

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