Assessment

First Name (required)	Last Name (required)	Email (required)
Phone Number	Referred by
Age (required)	Gender (required) Male Female

Please choose up to 8 conditions or symptoms below.

Conditions / Symptoms
A B C D E F G H I J K L M N O P R S T U V W Y

Abscesses (External)

Abscesses (Internal)

Acne

Acne Mask

Hyper Activiy and Focus

Addison's Disease

Adrenals

After Birth Pain

Age Spots

Allergies

Alzheimer's

Anemia

Angina Pectoris

Antibiotic

Antiseptics

Antispasmodic

Anxiety

Appendix Attack

Appetite Decrease

Appetite Increase

Arthritis

Asthma

Atherosclerosis

Athletes Foot

Autism

Back Pain

Bad Breath

Bed Sores

Bed Wetting

Bee Stings

Bell's Palsy

Beriberi

Bipolar

Bladder Infection

Bleeding

Bleeding Gums

Blood Poisoning

Blood Pressure

Blood Purifier

Boils

Bones

Bowels

Bronchitis

Bruises

Bruise Prevention

Burns

Cancer

Canker Sores

Cartilage Rebuilder

Cataracts

Chicken Pox

Child Birth

Cholesterol

Chronic Fatigue

Circulation

Cirrhosis

Colds

Cold Sores

Colic

Colitis

Colon Clense

Constipation

Cough

Cradle Cap

Cramps

Dandruff

Depression

Dermatitis

Diabetes

Diaper Rash

Diarrhea

Difficulty Breathing

Digestion Problems

Diverticulitis

Dizziness

Douche

Drowsiness

Drug Addiction

Drug Cleanse

Dry Skin

Earaches

Ear Ringing

Eating Disorder (Anorexia/Bulimia)

Edema

Endometriosis

Endurance

Energy

Environmental Poisoning

Epilepsy

Epstein-Barr Syndrome

Eyes

Eye Wash

False Labor

Fatigue

Fever (Infant)

Fever (Ages 6-9)

Fever (Ages 10-15)

Fever (Age 16+)

Fibromyalgia

Flatulence (Gas)

Flu

Food Allergy

Food Poisoning

Gall Stones

Gangrene

Ginger-Myrrh Bath

Gingivitis

Glaucoma

Gout

Gum Soreness

Hair Growth

Hardening of the Arteries

Hay Fever

Headache

Heart

Heart Attack

Heartburn

Hemorrhaging

Hemorrhoids

Hepatitis

Hernia

Herpes

Herpes (Oral)

Hiatal Hernia

Hiccups

High Blood Pressure

Hives

Hormone Imbalance (Female)

Hormone Imbalance (Male)

Hoarse Voice

Hot Flashes (Female)

Hot Flashes (Male)

Hypoglycemia (Low Blood Sugar)

Hysterectomy

Immune System Building

Impetigo

Impotency

Induce Labor

Infections

Infertility (Female)

Infertility (Male)

Insect Bites

Irritability

Insomnia

Intestinal Problems

Jaundice (Baby)

Joints

Kidney Flush

Kidney Stones

Labor Pains

Lactating/Milk Production

Laryngitis

Laxatives

Lead Poisoning

Leg Cramps

Libido

Lice

Liver

Lou Gehrig’s Disease

Low Blood Pressure

Low Blood Sugar

Lung Problems

Lupus

Lymphatic System

Macular Degeneration

Measles

Memory

Menstrual Problems

Menopause

Mercury Poisoning

Metal Poisoning

Migraine

Miscarriage

Moles

Mononucleosis

Morning Sickness

Motion Sickness

Mouth Sores

Multiple Sclerosis

Mumps

Muscles (Building)

Nephritis

Night Sweats (Female)

Night Sweats (Male)

Nose Bleeds

Nursing

Osteoporosis

Ovaries

Pain

Pancreas

Panic Attacks

Paranoia

Parasites

Parkinson’s

Phytotoxins

Pituitary

Pleurisy

Pneumonia

Pre-menstrual Syndrome

Poison Ivy or Oak

Pregnancy

Prolapsed Uterus

Prostate

Psoriasis

Pyorrhea

Restless Legs Syndrome

Rheumatism

Ring Worm

Scars

Senility

Seizure

Shingles

Sinuses

Skin Care

Skin Cancer

Spider Bites

Sore Throat

Staph Infection

Stomach Ache

Stop Smoking

Stress

Stroke

Sty

Teething

Tendonitis

Thrush

Thyroid

Tonsillitis

Toothache

Toxemia

Toxic Waste Poisoning

Tumors

Ulcers

Urinary Tract Infection

Urine Retention

Vaginal Problems

Varicose Veins

Warts

Whooping Cough

Wheezing

Yeast

Copyright © 2025 Total Health Response 2019. All Rights Reserved. These statements have not been evaluated by the Food & Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. † These indications are based solely on traditional homeopathic use. They have not been evaluated by the Food & Drug Administration.