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
2. Heartburn (burning of the esophagus due to stomach acid)Deselect Answer
3.Ulcers (stomach ulcerative)Deselect Answer
4. BelchingDeselect Answer
5. Hiatal hernia (birth defect)Deselect Answer
6. BloatingDeselect Answer
7. IndigestionDeselect Answer
8. Bowel gasDeselect Answer
9. Severe indigestionDeselect Answer
10. AllergiesDeselect Answer
11. Children born with birth defectsDeselect Answer
12. Chronic ConstipationDeselect Answer
13. DandruffDeselect Answer
14. Female--Gestal DiabetesDeselect Answer
15. DiarrheaDeselect Answer
16. Dry scalpDeselect Answer
17. Dry skinDeselect Answer
18. Family members with gluten problemsDeselect Answer
19. FatigueDeselect Answer
20. Food allergiesDeselect Answer
21. Low immunity-Get sick oftenDeselect Answer
22. Intestinal painDeselect Answer
23. Lactose intoleranceDeselect Answer
24. Low thyroid (basal body temperature 97.6 or lower)Deselect Answer
25. Outdoor allergiesDeselect Answer
26. Female-- Premature ChildbirthDeselect Answer
27. Female-- Premature ContractionsDeselect Answer
28. Rosacea (Redness of nose and cheeks)Deselect Answer
29. Fungal infection, yeast infection or thrush (Candida)Deselect Answer
30. Appendicitis or appendix removedDeselect Answer
31. Cancer (s)Deselect Answer
32. Celiac- Crohn's diseaseDeselect Answer
33. Celiac - DiverticulitisDeselect Answer
34. Celiac - Irritable BowelDeselect Answer
35. Celiac - Leaky GutDeselect Answer
36. Celiac - Ulcerative ColitisDeselect Answer
37. Cystic FibrosisDeselect Answer
38. Dementia - Alzheimer'sDeselect Answer
39. Dementia-Korsakoff's SyndromeDeselect Answer
40. Dementia-VascularDeselect Answer
41. Dementia - Wernicke - KorsakoffDeselect Answer
42. Female--Multiple Miscarriages (more than 2)Deselect Answer
43. LupusDeselect Answer
44. Muscular dystrophy and / or scoliosisDeselect Answer
45. Neurological - Huntington's diseaseDeselect Answer
46. Neurological - Lou Gehrig's disease (ALS)Deselect Answer
47. Neurological - multiple sclerosis (MS)Deselect Answer
48. Neurological - Parkinson's diseaseDeselect Answer
49. Neurological - Seizures or epilepsyDeselect Answer
50. Sickle cell anemiaDeselect Answer
51. Vitiligo (loss of color of the skin)Deselect Answer
52. Acne
Deselect Answer
53. Alopecia (hair loss)Deselect Answer
54. AsthmaDeselect Answer
55. Blood clotsDeselect Answer
56. Brittle hairDeselect Answer
57.Cardiovascular diseaseDeselect Answer
58. Cracked heels / cuticlesDeselect Answer
59. Dermatitis and eczema
Deselect Answer
60. Female-- Extended Menopause (over a year)Deselect Answer
61. Fibromyalgia
Deselect Answer
62. GallstonesDeselect Answer
63. Growth retardationDeselect Answer
64. Female-- Hormonal ImbalanceDeselect Answer
65. InfertilityDeselect Answer
66. Inflammation, including jointsDeselect Answer
67. Male--Low libido (SD)
Deselect Answer
68. Male--Low or no sperm count
Deselect Answer
69. Male-- No sperm motilityDeselect Answer
70. Gallbladder removedDeselect Answer
71. Psoriasis (Skin Condition)Deselect Answer
72. Female-- Irregular Menstrual CycleDeselect Answer
73. Female-- Premenstrual Syndrome( PMS)Deselect Answer
74. ADD / ADHD
Deselect Answer
75. Adrenal Exhaustion (Anxiety)
Deselect Answer
76. Bed wetting ( before midnight)
Deselect Answer
77. Bipolar disorder (PTSD)Deselect Answer
78. DepressionDeselect Answer
79. Diabetes Type 1
Deselect Answer
80. Diabetes Type 2Deselect Answer
81. DizzinessDeselect Answer
82. Elevated cholesterol and triglyceridesDeselect Answer
83. Excessive thirst, sweat or urinationDeselect Answer
84. Fainting spells
Deselect Answer
85. Hyperactivity
Deselect Answer
86. Learning disabilityDeselect Answer
87. Memory loss
Deselect Answer
88. Migraines headachesDeselect Answer
89. MoodinessDeselect Answer
90. Narcolepsy
Deselect Answer
91. Night sweats
Deselect Answer
92. Obesity
Deselect Answer
93. Peripheral Neuropathy
Deselect Answer
94. Reactive Hypoglycemia
Deselect Answer
95. Tired after Eating
Deselect Answer
96. ArthritisDeselect Answer
97. Rheumatoid Arthritis
Deselect Answer
98. Atrial FibrillationDeselect Answer
99. Back achesDeselect Answer
100. Bed wetting( after midnight)Deselect Answer
101. Bell's palsy (facial palsy of one side of the face)Deselect Answer
102. Bone spurs and fracturesDeselect Answer
103. Brittle nailsDeselect Answer
104. Calcium depositsDeselect Answer
105. Cartilage and ligaments damageDeselect Answer
106. Cognitive ImpairmentDeselect Answer
107. Disc-Herniated, bulging or rupturedDeselect Answer
108. Disc- DegenerativeDeselect Answer
109. Dowager's Hump (Hump)Deselect Answer
110. Elevated calcium levels in the bloodDeselect Answer
111. High Blood Pressure HighDeselect Answer
112. Hyper-parathyroidism (Rapid Thyroid)Deselect Answer
113. InsomniaDeselect Answer
114. IrritabilityDeselect Answer
115. Joint painDeselect Answer
116. Kidney stonesDeselect Answer
117. Muscle cramps, spasms and twitching
Deselect Answer
118. Myelofibrosis (myelosclerosis)
Deselect Answer
119. NervousnessDeselect Answer
120. Osteo-fibrosis (bone diseaseDeselect Answer
121. Osteoporosis
Deselect Answer
122.Female-- Preeclampsia
Deselect Answer
123. Prolonged coagulationDeselect Answer
124. Receding gumsDeselect Answer
125. Restless legsDeselect Answer
126. Retarded growthDeselect Answer
127. Sciatica (lower back pain)Deselect Answer
128. Tetany (Spasms of hands and feet)Deselect Answer
129. Tinnitus (ringing sound inside the ear)Deselect Answer
130. Tooth decayDeselect Answer
131. Trigeminal Nerve Neuralgia
Deselect Answer
132. Anemia (low blood iron count)Deselect Answer
133. AneurysmDeselect Answer
134. Arteriosclerosis (restricted blood flow)Deselect Answer
135. Burns( 1st, 2nd, and 3rd degree)Deselect Answer
136. Bursitis (inflammation by fluid in the joint cavity)Deselect Answer
137. Cataracts
Deselect Answer
138. FluDeselect Answer
139. GlaucomaDeselect Answer
140. GoutDeselect Answer
141. Graves' disease ( overactive thyroid)
Deselect Answer
142. Gray hairDeselect Answer
143. Stomach bacteria (H. Pylori)
Deselect Answer
144.Hashimoto’s disease(low thyroid)Deselect Answer
145. Hemorrhaging or nosebleedsDeselect Answer
146. HemorrhoidsDeselect Answer
147. Hot flashesDeselect Answer
148. Kidney dialysisDeselect Answer
149. Kidney FailureDeselect Answer
150. Female-- Limited or scarce lactationDeselect Answer
151. Lyme diseaseDeselect Answer
152. Macular degenerationDeselect Answer
153. Neurological damage (from stroke or brain tumor)Deselect Answer
154. Male-- Prostate issuesDeselect Answer
155. Notable scarringDeselect Answer
156. Stem cell rejuvenationDeselect Answer
157. Varicose veins or spider veinsDeselect Answer
158. Water retentionDeselect Answer