Copyright by the Common-Law
© 1996, AERAI
Circle 1 if slight or occasional, 2 if moderate,
3 if severe or frequent.
1. Energize
0 1 2 3 low physical energy
0 1 2 3 low mental energy
0 1 2 3 low adaptability
0 1 2 3 low resistance
0 1 2 3 low tolerance
0 1 2 3 out of balance
0 1 2 3 feel old
0 1 2 3 history of prolonged pharmaceutical or recreational drug
use
0 1 2 3 known drug reactions
0 1 2 3 drink treated, unfiltered water
0 1 2 3 history of vaccination
0 1 2 3 history of allergy shots
0 1 2 3 history of severe accidental or surgical trauma
0 1 2 3 history of general anesthesia
0 1 2 3 history of severe psychological shock
0 1 2 3 lack of will
0 1 2 3 lack of initiative
0 1 2 3 reduced vitality
0 1 2 3 feel depressed
0 1 2 3 getting progressively worse
0 1 2 3 total fatigue
0 1 2 3 tired all day long
0 1 2 3 laziness
0 1 2 3 good feelings don’t last long
0 1 2 3 short periods of aggression
0 1 2 3 reactions are brief
0 1 2 3 hunger pains
0 1 2 3 low blood sugar
0 1 2 3 problems with memory
0 1 2 3 problems with concentration
0 1 2 3 tired of life
0 1 2 3 indifferent
0 1 2 3 suicidal thoughts or feelings
0 1 2 3 life feels absurd
0 1 2 3 want to go away
0 1 2 3 feel like dissappearing
0 1 2 3 unstable
0 1 2 3 seem to cultivate paradoxes
0 1 2 3 indecisive
0 1 2 3 disordered
0 1 2 3 agitated
0 1 2 3 mentally perverse
0 1 2 3 sexual perversion
0 1 2 3 lack spirit
0 1 2 3 capricious
0 1 2 3 versatile
0 1 2 3 dissillusioned
0 1 2 3 work in intellectual environment
0 1 2 3 work in technical environment
0 1 2 3 overworked
0 1 2 3 problems brought out with stress, infection, or toxicity
0 1 2 3 irregular sleep
0 1 2 3 nightmares
0 1 2 3 insomnia
0 1 2 3 thin
0 1 2 3 weak
0 1 2 3 greyish skin
0 1 2 3 oily skin
0 1 2 3 thick skin
0 1 2 3 skin cold to the touch
0 1 2 3 skin dry to the touch
0 1 2 3 work at computers or electrical equipment
0 1 2 3 sleep near clock or other electrical device
0 1 2 3 any degenerative disease
0 1 2 3 bad joints or spine (e.g. rheumatism, scoliosis)
0 1 2 3 acute infections
0 1 2 3 recurrent infections
0 1 2 3 frequent bladder problems
0 1 2 3 pain or infection in bones
0 1 2 3 unexplained fever
0 1 2 3 any viral condition
0 1 2 3 cancer or leukemia
0 1 2 3 tuberculosis
0 1 2 3 any tissue degeneration
0 1 2 3 overall aging
________ Total Phase 1 Score
2. Rejuvenate
0 3 4 5 age in decades (less than 30 = 0,
30’s = 3, 40’s = 4, 50’s and up = 5)
0 1 2 3 nervous
0 1 2 3 emotional
0 1 2 3 easily depressed
0 1 2 3 agitated
0 1 2 3 anxious
0 1 2 3 creative spirit
0 1 2 3 mental aging
0 1 2 3 physical aging
0 1 2 3 poor memory
0 1 2 3 poor concentration
0 1 2 3 poor sleep pattern
0 1 2 3 fatigue increases through the day
0 1 2 3 fatigue worst in late afternoon
0 1 2 3 fatigue in legs
0 1 2 3 feel old
0 1 2 3 used to be more optimistic
0 1 2 3 circulatory problems
0 1 2 3 problems with bowels
0 1 2 3 urination problems
0 1 2 3 any rapid degeneration or deterioration
0 1 2 3 stressed or out of balance
0 1 2 3 hemorrhoids
0 1 2 3 varicose veins
0 1 2 3 varicose eczema
0 1 2 3 phlebitis
0 1 2 3 blood pressure varies
0 1 2 3 cardiovascular problems
0 1 2 3 swelling in legs
0 1 2 3 pain or tenderness in legs
0 1 2 3 circulatory pains
0 1 2 3 digestive upsets
0 1 2 3 ulcers
0 1 2 3 stomach pain
0 1 2 3 spasms in blood vessels or digestive area
0 1 2 3 stomach spasms
0 1 2 3 only small amount of urine production
0 1 2 3 kidney stones
0 1 2 3 pain with urination
0 1 2 3 low back pain
0 1 2 3 hives
0 1 2 3 chronic eczema
0 1 2 3 swelling of skin
0 1 2 3 flushed nose and cheeks
0 1 2 3 dislike being touched
0 1 2 3 head drawn back and to one side
0 1 2 3 cramp in calves
0 1 2 3 night cramps
0 1 2 3 cardiac asthma
0 1 2 3 headaches in the back of the head
0 1 2 3 degenerative joint problems
0 1 2 3 disturbances related to menopause
0 1 2 3 congestion around the hips and pelvis
0 1 2 3 hardening of the arteries
0 1 2 3 inflamed nerves
0 1 2 3 mental disturbances with anxiety
0 1 2 3 overweight
0 1 2 3 gout attacks
________ Total Phase 2 Score
3. Regenerate
0 1 2 3 calm
0 1 2 3 deliberate
0 1 2 3 even-tempered
0 1 2 3 balanced nature
0 1 2 3 indifferent
0 1 2 3 not easily upset
0 1 2 3 poor concentration
0 1 2 3 difficulty paying attention
0 1 2 3 distractable
0 1 2 3 dyslexic
0 1 2 3 nonchalant
0 1 2 3 methodical
0 1 2 3 good self control
0 1 2 3 economical use of energy
0 1 2 3 speak little
0 1 2 3 speak only about what is of interest
0 1 2 3 sentiments aroused slowly
0 1 2 3 sentiments aroused passively
0 1 2 3 sentiments are continous once aroused
0 1 2 3 profound knowledge, rather than brilliant intelligence
0 1 2 3 easily tired
0 1 2 3 lack physical resistance
0 1 2 3 energy decreases through the day
0 1 2 3 energy decreases with effort
0 1 2 3 feel tired when relaxed
0 1 2 3 sleep is absolutely necessary
0 1 2 3 rest breaks are necessary
0 1 2 3 holidays are essential
0 1 2 3 round or oval face
0 1 2 3 small hands
0 1 2 3 fine skin
0 1 2 3 white or pale skin
0 1 2 3 cold skin
0 1 2 3 body rounded and larger at pelvis
0 1 2 3 flabby tendency
0 1 2 3 family history of lung problems
0 1 2 3 bacterial infections
0 1 2 3 viral infections
0 1 2 3 fungal problems
0 1 2 3 stable conditions
0 1 2 3 chronic conditions
0 1 2 3 sensitive respiratory tract
0 1 2 3 sensitive mucus membranes
0 1 2 3 lymphatic reactions (e.g. swollen glands)
0 1 2 3 digestive reactions
0 1 2 3 pain in intestines, or colitis
0 1 2 3 immune dysfunction
0 1 2 3 slow development
0 1 2 3 allergy to foods or drugs
0 1 2 3 hives
0 1 2 3 eczema
0 1 2 3 acne
0 1 2 3 headaches
0 1 2 3 arthritis
0 1 2 3 diabetes
0 1 2 3 overweight
0 1 2 3 inflamed connective tissue, or cellulitis
0 1 2 3 nutritional disturbances
0 1 2 3 any inflammation
0 1 2 3 persistent minor health problems
0 1 2 3 loose ligaments or joints
0 1 2 3 poor bladder control (e.g. bedwetting)
0 1 2 3 bronchial asthma
0 1 2 3 arthritis or inflamed joints
0 1 2 3 disturbance of elimination functions
0 1 2 3 hypothyroid
0 1 2 3 scanty menses
0 1 2 3 skipped periods
0 1 2 3 small genitals
0 1 2 3 adrenal exhaustion
________ Total Phase 3 Score
4. Cleanse
0 1 2 3 energetic
0 1 2 3 voluntary
0 1 2 3 impetuous
0 1 2 3 exalted
0 1 2 3 needs action
0 1 2 3 spirit of initiative
0 1 2 3 vitality
0 1 2 3 youthfulness
0 1 2 3 optimism
0 1 2 3 self confidence
0 1 2 3 nervous
0 1 2 3 irritable
0 1 2 3 quick tempered
0 1 2 3 inconstant in performance
0 1 2 3 constant in feelings
0 1 2 3 poor continuity of effort
0 1 2 3 choleric
0 1 2 3 easily frustrated
0 1 2 3 objective
0 1 2 3 open minded
0 1 2 3 adaptable
0 1 2 3 hard to get up in morning
0 1 2 3 morning fatigue
0 1 2 3 energy improves with effort
0 1 2 3 overactive in the evening
0 1 2 3 insomnia
0 1 2 3 muscular hyperfunction
0 1 2 3 robust body
0 1 2 3 rectangular body
0 1 2 3 square hands
0 1 2 3 sallow complexion
0 1 2 3 matt skin surface
0 1 2 3 warm skin
0 1 2 3 dry skin
0 1 2 3 periodic migraines
0 1 2 3 allergies (airborne or contact)
0 1 2 3 urticaria
0 1 2 3 eczema
0 1 2 3 pruritis
0 1 2 3 asthma
0 1 2 3 upper respiratory problems
0 1 2 3 rhinitis
0 1 2 3 hay fever
0 1 2 3 algias
0 1 2 3 arthritis
0 1 2 3 nervous heart symptoms (e.g. precoralgia)
0 1 2 3 tachycardia
0 1 2 3 nervous upsets to digestion or intestines
0 1 2 3 biliary blockage (gastro-duodenal, icterus)
0 1 2 3 gout
0 1 2 3 mild urinary disturbances
0 1 2 3 hyperthyroid
0 1 2 3 hypermenorrhea (a type of dysmenorrhea)
0 1 2 3 hyperfolliculinia
0 1 2 3 hemorrhoids
0 1 2 3 psychosomatic symptoms
0 1 2 3 family history of psychosomatic problems
0 1 2 3 family history of eczema, asthma, allergies, urticaria,
or migraines
________ Total Phase 4 Score
5. Balance (Endocrine/Maladaptation)
0 1 2 3 periodic tiredness
0 1 2 3 irregularly timed fatigue
0 1 2 3 hunger pangs with tiredness
0 1 2 3 intellectual depression
0 1 2 3 temporary vacuities of any mental capacity
0 1 2 3 pituitary problems
0 1 2 3 endocrine dysfunction
0 1 2 3 genital problems
0 1 2 3 adrenal imbalance
0 1 2 3 developmental retardation
0 1 2 3 enuresis
0 1 2 3 cryptorchidism
0 1 2 3 sexual indifference
0 1 2 3 sexual impotence
0 1 2 3 prostate dysfunction
0 1 2 3 pancreas problems
0 1 2 3 genital adiposity
0 1 2 3 hair disturbances
0 1 2 3 total loss of hair
0 1 2 3 nail disturbances
0 1 2 3 stress
________ Total Phase 5 Score
Scoring:
| Phase |
1 |
2 |
3 |
4 |
5 |
| Total Phase Score |
|
|
|
|
|
| # of questions |
75 |
58 |
63 |
70 |
21 |
| Score = (total/#) x 100% |
% |
% |
% |
% |
% |
The following minimum programs are suggested
based on your Phase with the highest percentage Score:
Phase 1:
Product Low Dosage Bottles/Mo. High Dosage Bottles/Mo.
Star Gold 1/4x2 1/2 1/2x2 1
Shark Essence 1/2x2 1 1x2 2
Energessence 1/2x2 1 1x2 2
Friendly Flora 1x1 1/3 1x3 1
Pycnogenol + 1x1 1 1x2 2
Phase 2:
Product Low Dosage Bottles/Mo. High Dosage Bottles/Mo.
Star Gold 1/4x2 1/2 1/2x2 1
Digestzymes 1/2x2 1 1x3 3
Energessence 1/2x2 1 1x2 2
Friendly Flora 1x1 1/3 1x3 1
Pycnogenol + 1x1 1 1x2 2
Phase 3:
Product Low Dosage Bottles/Mo. High Dosage Bottles/Mo.
Star Gold 1/4x2 1/2 1/2x2 1
A to Z 1/2x2 1 1x2 2
Energessence 1/2x2 1 1x2 2
Friendly Flora 1x1 1/3 1x3 1
Pau D’Arco 1x3 1 2x3 2
Phase 4:
Product Low Dosage Bottles/Mo. High Dosage Bottles/Mo.
Star Gold 1/4x2 1/2 1/2x2 1
Stamina Plus 1/2x2 1 1x2 2
Energessence 1/2x2 1 1x2 2
Friendly Flora 1x1 1/3 1x3 1
Star Fiber 1x2 1/2 1x4 1
Phase 5:
Product Low Dosage Bottles/Mo. High Dosage Bottles/Mo.
Star Gold 1/4x2 1/2 1/2x2 1
Stamina Plus 1/2x2 1 1x2 2
Energessence 1/2x2 1 1x2 2
Friendly Flora 1x1 1/3 1x3 1
You may want to add other supplements to
your program as desired, based on your unique individual needs.
Check your scores on this questionnaire every 3 months or when you
experience a major change in symptoms to determine when and how
to shift programs. Biofield Analysis can further individualize your
program.
