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.
Healthy Grease Monkey 