Virtual Body Scan Questionnaire

Connecting the Dots to Achieve Optimum Health!

     Name___________________________________________________________________________________

       Tel. No./Email__________________________________________________________________________

       What is your health concern?_________________________________________________________

        Mark with a dot each item that you have experienced:

• Musculoskeletal disorders (muscles, joints) _____
• Neurogenic (nerve disorders) _____
• Psychogenic (emotional issues, blocks) _____
• Hormonal imbalances _____
• Eating disorders _____
• Dental problems (teeth, gums, mouth sores) ____
• Inflammation (muscles, joints, gums, etc.) ____
• Pain ____
• Infections (bacteria, viral, fungal) ____
• Spinal disorders (neck, mid-back, lower back) ____
• Environmental allergies (mold, pollen) ____
• Vascular problems (circulation, numbness, tingling, cold extremities) ____
• Sugar consumption ____
• Organs/Endocrine disorders (digestive, respiratory, thyroid, etc.) ____
• Chemical sensitivities ____

Return questionnaire to Dr. Robert Friedman

www.VirtualBodyScan.com

drrobert@drrobert.com

Fax: 941-475-3967

Questions:  800-538-4973