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• Learning is the beginning of Health& Wealth !

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Health Test

Health Test

60-Second Health Test

Name:

Phone:

Date:

Use the Personal Evaluation sheet to assess your present condition and to chart your progress. To start, Choose yes or no next to the conditions that apply to you. Rate the level of your condition from 1 being minor to 10 for maximum health impact. This exercise will help you recall how you felt prior to starting the program and enable you to measure your progress.

Before using Shopfreemart Products
Do you have any of these symptoms?

1. Aching Joints

Yes

No

---

2. ADD/ADHD (attention & focus)

Yes

No

---

3. Arthritis Joint mobility

Yes

No

---

4. Allergies/Hay fever

Yes

No

---

5. Back Pain (back health)

Yes

No

---

6. Belching, Burping, Gas after Meals

Yes

No

---

7. Brittle Fingernails/Limp, Dry Hair

Yes

No

---

8. Body Odor/Bad Breath

Yes

No

---

9. Cancer (cellular health)

Yes

No

---

10. Circulation

Yes

No

---

11. Cholesterol

Yes

No

---

12. Cuts and Bruises Heal Slowly

Yes

No

---

13. Cravings for Sweets/Salts

Yes

No

---

14. Cold Hands and Feet

Yes

No

---

15. Constipation or Diarrhea

Yes

No

---

16. Cellulite

Yes

No

---

17. Diabetes (blood sugar)

Yes

No

---

18. Difficulty Handling Stress

Yes

No

---

19. Depression (emotional health)

Yes

No

---

20. Difficulty Getting Up in Morning

Yes

No

---

21. Difficulty Falling Asleep

Yes

No

---

22. Difficulty Losing Weight

Yes

No

---

23. Fibromyalgia

Yes

No

---

24. Frequent Colds and Infections

Yes

No

---

25. Frequently Take Pain Killers

Yes

No

---

26. Gallstones (gallbladder)

Yes

No

---

27. Heart/Lung Symptoms

Yes

No

---

28. Headaches/Migraines

Yes

No

---

29. High/Low Blood Pressure

Yes

No

---

30. Heartburn/Indigestion

Yes

No

---

31. Hemorrhoids

Yes

No

---

32. Hair Loss

Yes

No

---

33. Low Endurance Level

Yes

No

---

34. Low Sex Drive

Yes

No

---

35. Muscle Cramps

Yes

No

---

36. Menopausal Symptoms

Yes

No

---

37. Menstrual Cramps/Mood /PMS

Yes

No

---

38. Often Feel Bloated

Yes

No

---

39. Osteoporosis (bone loss)

Yes

No

---

40. Prostate Health

Yes

No

---

41. Poor Concentration

Yes

No

---

42. Poor Memory

Yes

No

---

43. Yeast/Fungus

Yes

No

---

44. Eye Symptoms

Yes

No

---

45. Night Vision/ Halo's Around Lights

Yes

No

---

46. Skin Problems/ Dry/ Itchy/ Acne

Yes

No

---

47. Shortness of Breath

Yes

No

---

48. Frequent Urinary Tract Symptoms

Yes

No

---

49. Varicose Veins/ Spider Veins

Yes

No

---

50. Water Retention / Edema

Yes

No

---

Other symptoms and notations

What FreeMart products do you take regularly?

 Hydration Drops

 Freemart IEE

 D-Cal Boron™

 Sugar-D™

 Pure Nature Nutrients

 Pure MAG Concentrate

 Pure Copper Concentrate

 Pure Silver Concentrate

 Pure Gold Concentrate

 Nano Cards

 Nviro Soap Products

How many glasses of water do you drink each day?                  - Please select -                 12345678910               

Do you artificial sweeteners/diet products?

Yes

No

Do you consume coffee, tea, or soda pop daily?

Yes

No

Do you wish to lose weight or gain weight?

Lose Weight

Gain Weight

Do you smoke or chew tobacco daily?

Yes

No

Do you drink alcohol?

Yes

No

Suggestions:

• Drink a minimum of 8 glasses of Hydration Drops a day.
• Stay consistent with the product.
• Exercise regularly for best results.

These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. This Personal Evaluation is for informational purposes only and is not intended to diagnose, treat, cure or prevent any disease.