Take Our Free Health Questionnaire
RequiredRequired Question(s)
This questionnaire represents many of the issues that our clients face. We hope it will help you pinpoint the areas of your health that are the most critical for you!

We also invite you to schedule a call or appointment with Victoria, Our Board Certified Holistic Practitioner, who will discuss with you the results of your questionnaire and determine the best course of action for Significant Healing!

Please allow 15 minutes to take the questionnaire and go through each section thoroughly. On a mobile device, switch to landscape or horizontal view for the best viewing.

Complete the contact form at the end so we can reach out to you. We only access your answers for your personal consultations. Your information will not be shared with anyone and will be protected. 
 
1.
Dark Circles Under Eyes
Swollen Eyelids
Sticky Eyelids
Itchy Eyes
Reddened Eyelids
Blurred Vision
Watering Eyes
Tunnel Vision
Other  
2.

Genital Discharge
Genital Itching
Frequent Need to Urinate
Vaginal Yeast Infections
Other  
3.
Choose only the Reproductive/Hormone-Related Issues you experience regularly or severely.
Early Menopause
Infertility
Irregular Periods
Heavy Periods
Hot Flashes
Other  
4.

Stuffy Nose
Excessive Mucous
Sinus Problems
Hay Fever
Sneezing Attacks
Other  
5.
Itchy Ears
Ear Infections
Hearing Loss
Clogged Ears
Ear Aches
Drainage from Ears
Other  
6.

Discolored Lips
Frequent Need to Clear Throat
Swollen Tongue
Swollen Gums
Hoarseness
Amalglam Dental Fillings (Past or Present)
Chronic Coughing
Sore Throat
Swollen Lips
Discolored Gums
Gagging
Canker Sores
Discolored Tongue
Other  
7.

Dizziness
Insomnia
Headaches
Faintness
Migraines
Other  
8.

Chest Congestion
Asthma
Bronchitis
Shortness of Breath
Difficulty Breathing
Other  
9.

Stiffness
Pain in Muscles
Weakness
Limited Movement
Osteoarthritis
Rheumatoid Arthritis
Aches in Joints
Aches in Muscles
Tireness
Arthritis
Pain in Joints
Other  
10.

Fear
Anger
Irritability
Depression
Nervousness
Mood Swings
Anxiety
Other  
11.

Skipped Heartbeats
Chest Pain
Tightness in Chest
Rapid Heartbeats
Other  
12.
Poor Memory
Poor Concentration
Stammering
Stuttering
Brain Fog
Foggy Feeling
Dyslexia
Neurologic Disturbances
Cerebral Palsy
Shaking
Confusion
Blackouts
Seizures
Difficulty Making Decisions
Slurred Speech
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder
Other  
13.
Lethargy
Fatigue
Restlessness
Sluggishness
Apathy
Hyperactivity
Other  
14.

Acne
Hives
Rashes
Excessive Sweating
Hot Flashes
Dry Skin
Skin Fungus
Flushing
Hair Loss
Psoriasis
Athlete's Foot
Eczema
Tattoos
15.

Nausea
Vomitting
Belching
Passing Gas
Diarrhea
Constipation
Digestive Burn
Bloated Feeling
Yeast Infection (Candida)
Parasites
16.
Binge Eating
Excessive Weight
Water Retention
Binge Drinking
Compulsive Eating
Daily Consumption of Sugar
Daily Consumption of Packaged Foods
Craving Certain Foods (Please add these foods to the comments section below)
Underweight
Other  
17.
Taking Prescription Medication
Frequent Illness
Taking Over the Counter Medication
Other  
  • Comment:

  • 500 characters left.
18.
One more question:  Which three of these health issues are you the most concerned with right now? 
Eye-Related
Ear-Related
Mouth/Throat-Related
Nose-Related
Heart-Related
Lung-Related
Urinary-Related
Mind-Related
Energy-Related
Brain-Related
Skin-Related
Emotion-Related
Digestion Related
Joint/Muscle Related
Reproductive/Hormone--
Related
Head-Related
Required 19.
Be thinking about where you need to make changes to improve your health and be watching for tips and recommendations from Victoria! 

Your privacy will be protected. Your answers will not be shared with anyone or used for any purpose other than your personal consultations with Victoria.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
State/Province
(US/Canada):