Dr. Wallach's Free Health Survey

PLEASE NOTE: It is very important that you complete this Health Survey BEFORE using Dr. Wallach's products.

All personal information is kept confidential. Results can take up to 48 hours. Once you complete and submit the survey, be on alert for an email with the subject line, titled "Link to Schedule your Free Nutritional Consultation," which you will use to schedule your FREE phone consultation. During this brief call, we will discuss the results of your evaluation with the corresponding protocol that our system generated. We will also assist you in selecting the best Health Pack to meet your specific needs and your budget.

How this Evaluation Works:
The information you submit in this survey goes through programming (algorithms) that uses an extensive database that reflects the philosophy of Dr. Joel Wallach. These algorithms are programmed to capture information such as your age, weight, height, gender, and nutritional deficiency symptoms, and together with Dr. Wallach's database, it develops an individualized nutritional supplement protocol.

Date:

First Name:

Last Name:

Phone Number:

Email address:

Your Country of Residence:

Your State or Province:

Zip/Postal Code:

Age:

What is your most important health goal in the next 90 days?

Height

Feet

Inches

Weight

What is your monthly budget? How much can you spend each month to meet your 90 Day Health Goal?

Have you ever used Dr. Wallach's products?

1. Acid refluxDeselect Answer

Yes

2. Heartburn (burning of the esophagus due to stomach acid)Deselect Answer

Yes

3.Ulcers (stomach ulcerative)Deselect Answer

Yes

4. BelchingDeselect Answer

Yes

5. Hiatal hernia (birth defect)Deselect Answer

Yes

6. BloatingDeselect Answer

Yes

7. IndigestionDeselect Answer

Yes

8. Bowel gasDeselect Answer

Yes

9. Severe indigestionDeselect Answer

Yes

10. AllergiesDeselect Answer

Yes

11. Children born with birth defectsDeselect Answer

Yes

12. Chronic ConstipationDeselect Answer

Yes

13. DandruffDeselect Answer

Yes

14. Female--Gestal DiabetesDeselect Answer

Yes

15. DiarrheaDeselect Answer

Yes

16. Dry scalpDeselect Answer

Yes

17. Dry skinDeselect Answer

Yes

18. Family members with gluten problemsDeselect Answer

Yes

19. FatigueDeselect Answer

Yes

20. Food allergiesDeselect Answer

Yes

21. Low immunity-Get sick oftenDeselect Answer

Yes

22. Intestinal painDeselect Answer

Yes

23. Lactose intoleranceDeselect Answer

Yes

24. Low thyroid (basal body temperature 97.6 or lower)Deselect Answer

Yes

25. Outdoor allergiesDeselect Answer

Yes

26. Female-- Premature ChildbirthDeselect Answer

Yes

27. Female-- Premature ContractionsDeselect Answer

Yes

28. Rosacea (Redness of nose and cheeks)Deselect Answer

Yes

29. Fungal infection, yeast infection or thrush (Candida)Deselect Answer

Yes

30. Appendicitis or appendix removedDeselect Answer

Yes

31. Cancer (s)Deselect Answer

Yes

32. Celiac- Crohn's diseaseDeselect Answer

Yes

33. Celiac - DiverticulitisDeselect Answer

Yes

34. Celiac - Irritable BowelDeselect Answer

Yes

35. Celiac - Leaky GutDeselect Answer

Yes

36. Celiac - Ulcerative ColitisDeselect Answer

Yes

37. Cystic FibrosisDeselect Answer

Yes

38. Dementia - Alzheimer'sDeselect Answer

Yes

39. Dementia-Korsakoff's SyndromeDeselect Answer

Yes

40. Dementia-VascularDeselect Answer

Yes

41. Dementia - Wernicke - KorsakoffDeselect Answer

Yes

42. Female--Multiple Miscarriages (more than 2)Deselect Answer

Yes

43. LupusDeselect Answer

Yes

44. Muscular dystrophy and / or scoliosisDeselect Answer

Yes

45. Neurological - Huntington's diseaseDeselect Answer

Yes

46. Neurological - Lou Gehrig's disease (ALS)Deselect Answer

Yes

47. Neurological - multiple sclerosis (MS)Deselect Answer

Yes

48. Neurological - Parkinson's diseaseDeselect Answer

Yes

49. Neurological - Seizures or epilepsyDeselect Answer

Yes

50. Sickle cell anemiaDeselect Answer

Yes

51. Vitiligo (loss of color of the skin)Deselect Answer

Yes

52. Acne
Deselect Answer

Yes

53. Alopecia (hair loss)Deselect Answer

Yes

54. AsthmaDeselect Answer

Yes

55. Blood clotsDeselect Answer

Yes

56. Brittle hairDeselect Answer

Yes

57.Cardiovascular diseaseDeselect Answer

Yes

58. Cracked heels / cuticlesDeselect Answer

Yes

59. Dermatitis and eczema
Deselect Answer

Yes

60. Female-- Extended Menopause (over a year)Deselect Answer

Yes

61. Fibromyalgia
Deselect Answer

Yes

62. GallstonesDeselect Answer

Yes

63. Growth retardationDeselect Answer

Yes

64. Female-- Hormonal ImbalanceDeselect Answer

Yes

65. InfertilityDeselect Answer

Yes

66. Inflammation, including jointsDeselect Answer

Yes

67. Male--Low libido (SD)
Deselect Answer

Yes

68. Male--Low or no sperm count
Deselect Answer

Yes

69. Male-- No sperm motilityDeselect Answer

Yes

70. Gallbladder removedDeselect Answer

Yes

71. Psoriasis (Skin Condition)Deselect Answer

Yes

72. Female-- Irregular Menstrual CycleDeselect Answer

Yes

73. Female-- Premenstrual Syndrome( PMS)Deselect Answer

Yes

74. ADD / ADHD
Deselect Answer

Yes

75. Adrenal Exhaustion (Anxiety)
Deselect Answer

Yes

76. Bed wetting ( before midnight)
Deselect Answer

Yes

77. Bipolar disorder (PTSD)Deselect Answer

Yes

78. DepressionDeselect Answer

Yes

79. Diabetes Type 1
Deselect Answer

Yes

80. Diabetes Type 2Deselect Answer

Yes

81. DizzinessDeselect Answer

Yes

82. Elevated cholesterol and triglyceridesDeselect Answer

Yes

83. Excessive thirst, sweat or urinationDeselect Answer

Yes

84. Fainting spells
Deselect Answer

Yes

85. Hyperactivity
Deselect Answer

Yes

86. Learning disabilityDeselect Answer

Yes

87. Memory loss
Deselect Answer

Yes

88. Migraines headachesDeselect Answer

Yes

89. MoodinessDeselect Answer

Yes

90. Narcolepsy
Deselect Answer

Yes

91. Night sweats
Deselect Answer

Yes

92. Obesity
Deselect Answer

Yes

93. Peripheral Neuropathy
Deselect Answer

Yes

94. Reactive Hypoglycemia
Deselect Answer

Yes

95. Tired after Eating
Deselect Answer

Yes

96. ArthritisDeselect Answer

Yes

97. Rheumatoid Arthritis
Deselect Answer

Yes

98. Atrial FibrillationDeselect Answer

Yes

99. Back achesDeselect Answer

Yes

100. Bed wetting( after midnight)Deselect Answer

Yes

101. Bell's palsy (facial palsy of one side of the face)Deselect Answer

Yes

102. Bone spurs and fracturesDeselect Answer

Yes

103. Brittle nailsDeselect Answer

Yes

104. Calcium depositsDeselect Answer

Yes

105. Cartilage and ligaments damageDeselect Answer

Yes

106. Cognitive ImpairmentDeselect Answer

Yes

107. Disc-Herniated, bulging or rupturedDeselect Answer

Yes

108. Disc- DegenerativeDeselect Answer

Yes

109. Dowager's Hump (Hump)Deselect Answer

Yes

110. Elevated calcium levels in the bloodDeselect Answer

Yes

111. High Blood Pressure HighDeselect Answer

Yes

112. Hyper-parathyroidism (Rapid Thyroid)Deselect Answer

Yes

113. InsomniaDeselect Answer

Yes

114. IrritabilityDeselect Answer

Yes

115. Joint painDeselect Answer

Yes

116. Kidney stonesDeselect Answer

Yes

117. Muscle cramps, spasms and twitching
Deselect Answer

Yes

118. Myelofibrosis (myelosclerosis)
Deselect Answer

Yes

119. NervousnessDeselect Answer

Yes

120. Osteo-fibrosis (bone diseaseDeselect Answer

Yes

121. Osteoporosis
Deselect Answer

Yes

122.Female-- Preeclampsia
Deselect Answer

Yes

123. Prolonged coagulationDeselect Answer

Yes

124. Receding gumsDeselect Answer

Yes

125. Restless legsDeselect Answer

Yes

126. Retarded growthDeselect Answer

Yes

127. Sciatica (lower back pain)Deselect Answer

Yes

128. Tetany (Spasms of hands and feet)Deselect Answer

Yes

129. Tinnitus (ringing sound inside the ear)Deselect Answer

Yes

130. Tooth decayDeselect Answer

Yes

131. Trigeminal Nerve Neuralgia
Deselect Answer

Yes

132. Anemia (low blood iron count)Deselect Answer

Yes

133. AneurysmDeselect Answer

Yes

134. Arteriosclerosis (restricted blood flow)Deselect Answer

Yes

135. Burns( 1st, 2nd, and 3rd degree)Deselect Answer

Yes

136. Bursitis (inflammation by fluid in the joint cavity)Deselect Answer

Yes

137. Cataracts
Deselect Answer

Yes

138. FluDeselect Answer

Yes

139. GlaucomaDeselect Answer

Yes

140. GoutDeselect Answer

Yes

141. Graves' disease ( overactive thyroid)
Deselect Answer

Yes

142. Gray hairDeselect Answer

Yes

143. Stomach bacteria (H. Pylori)
Deselect Answer

Yes

144.Hashimoto’s disease(low thyroid)Deselect Answer

Yes

145. Hemorrhaging or nosebleedsDeselect Answer

Yes

146. HemorrhoidsDeselect Answer

Yes

147. Hot flashesDeselect Answer

Yes

148. Kidney dialysisDeselect Answer

Yes

149. Kidney FailureDeselect Answer

Yes

150. Female-- Limited or scarce lactationDeselect Answer

Yes

151. Lyme diseaseDeselect Answer

Yes

152. Macular degenerationDeselect Answer

Yes

153. Neurological damage (from stroke or brain tumor)Deselect Answer

Yes

154. Male-- Prostate issuesDeselect Answer

Yes

155. Notable scarringDeselect Answer

Yes

156. Stem cell rejuvenationDeselect Answer

Yes

157. Varicose veins or spider veinsDeselect Answer

Yes

158. Water retentionDeselect Answer

Yes

Time is Up!

Time's up

Living healthier starts here

Email

healingwithminerals90@gmail.com

Phone

1-800-201-8102

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HEALING WITH MINERALS

Schedule Your FREE Nutritional consultation
Free Health Evaluation
90 Essential Nutrients
Dr. Wallach
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These statements have not been evaluated by the FDA. This is not intended to diagnose, treat, cure or prevent any disease.
Proposition 65 Warning: Chemicals known to the State of California have said to cause cancer or birth defects or other reproductive harm may be present in some products sold here.

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Dr. Wallach's Free Health Survey

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