Health Evaluation Questionnaire

This "Health Evaluation Questionnaire" is adapted* from the book "Getting Started With Mangosteen" by Isa Navarre

*Dr. Templeman recommends taking Mangosteen juice WITH FOOD, up to a half hour before eating. The healing compounds of Mangosteen are enhanced when combined with some fat from food to "bind" with during digestion. Or, take with another supplement that contains essential fatty acids.

This Questionnaire helps us to figure out how much Mangosteen Juice to take
each day -- use it for yourself, or you can copy & paste it into a blank email to send
to others.

TIP: Complete the Questionnaire before taking Mangosteen juice, and then re-take periodically afterwards. You do not have to share this Questionnaire with anyone... it's your own personal record to help you understand what Mangosteen is doing for you.

Health Evaluation Questionnaire

Name:________________________________________________
Date:_____________________
Body Weight: _______________

Rate yourself on a scale from 1 to 5 and circle your answer:
1 No symptoms
2 Occasional or mild symptoms
3 Frequent, increasing or moderate symptoms
4 Daily symptoms that are tolerable
5 Daily symptoms that are difficult or very painful

1. My eyesight
1 2 3 4 5
2. My hearing
1 2 3 4 5
3. My mouth, gums and teeth
1 2 3 4 5
4. My throat and neck
1 2 3 4 5
5. My back and shoulders
1 2 3 4 5
6. My arms and legs, including elbows and knees
1 2 3 4 5
7. My hands and feet, including wrists and ankles
1 2 3 4 5
8. My circulation
1 2 3 4 5
9. My heart and cardiovascular health
1 2 3 4 5
10. My digestive tract, including stomach and colon
1 2 3 4 5
11. My blood sugar levels
1 2 3 4 5
12. How I feel after I eat
1 2 3 4 5
13. My bowel regularity
1 2 3 4 5
14. My bladder and urinary tract
1 2 3 4 5
15. My lungs and bronchial tubes
1 2 3 4 5
16. Any allergies?
1 2 3 4 5
17. My skin
1 2 3 4 5
18. How I feel when I wake up
1 2 3 4 5
19. How I feel when I go to bed
1 2 3 4 5
20. Who often I have pain anywhere in my body
1 2 3 4 5
21. How often I get headaches
1 2 3 4 5
22. My reproductive organs
1 2 3 4 5
23. My libido
1 2 3 4 5
24. My menstrual cycles (women)
1 2 3 4 5
25. My prostate (men)
1 2 3 4 5
26. My emotional balance and well being
1 2 3 4 5
27. My memory and mental clarity
1 2 3 4 5
28. Any feelings of depression?
1 2 3 4 5
29. My energy level
1 2 3 4 5
30. My stamina (endurance and ability to
withstand stress) 1 2 3 4 5
31. My immune system
1 2 3 4 5

Calculating Your Wellness Index:
Add up the numbers you have circled. Their sum is your Wellness Index.
My Wellness Index number is ________________

Your Mangosteen Dosage Chart
To find your suggested mangosteen dosage, fill in the flanks on the following chart by adding up how many 1's, 2's, 3's, 4's and 5's that you circled.

I circled _________________ 1's

I circled _________________ 2's

I circled _________________ 3's

I circled _________________ 4's

I circled _________________ 5's

If you circled only 1's and 2's, you are probably in very good health. Begin with a Maintenance Dose.
If you circled any 3's but no 4's or 5's, your health is beginning to show signs of challenges. Begin with a Loading Dose and then follow the procedure for taking a Maintenance Dose.
If you circled any 4's, your body needs help right away. Begin with a Health Improvement Dose #1.
If you circled any 5's, your body needs an aggressive approach to health improvement. Begin with Health Improvement Dose #2.

Suggested Amounts for drinking Mangosteen Juice

-- Maintenance Dose.
For those with excellent health.
1. The average Maintenance does for an average adult is one ounce of Mangosteen juice a day. This may be increased to two ounces during times of stress or illness. Take them within a half hour before eating some food.
2. Athletes may prefer to take 2 ounces, and if you are large framed or overweight you may want to take more. If you are small framed or under 100 lbs you may only need an ounce or a tablespoonful a day.

-- Loading Dose
This allows you to address any possible nutritional deficiencies in a much shorter time and to saturate your body with the mangosteen healing compounds.
1. Take two ounces (1/4 cup) of mangosteen twice a day. Take your second dose at least 4-6 hours after the first. If you want or feel you need to, try a third two-ounce dose. Take them within a half hour before eating some food.
2. Follow the Loading Dose for seven days which will require about one bottle of mangosteen.

-- Health Improvement Dose #1
These amounts are for those with chronic, acute or serious conditions, for preparing your body before surgery and helping it to recover afterward, for helping your body to heal after surgery, and so on. This dosage level is if you circled one or more 4's but no 5's.
1. Take four to six ounces of mangosteen a day for at least two weeks. Spread the ounces throughout the day. Take them on an empty stomach, two ounces at a time.
2. When your symptoms improve, reduce your daily dosage to a maintenance level. If your symptoms start to return, resume this procedure.

-- Health Improvement Dose #2
Mangosteen juice. Health Improvement Does #2 is a more aggressive approach. Try it if you circled any 5's.
1. Take eight to twelve ounces of mangosteen a day. The more serious you consider your condition, the higher your daily amount should be. Spread the ounces throughout the day. Take them within a half hour before eating some food, two ounces at a time.
2. When your symptoms improve, reduce your daily dosage by one or two ounces. Take this amount daily for another two weeks.
3. If your symptoms continue to improve, reduce your daily dosage by another ounce or two. Take this amount for another two weeks. Continue to reduce your daily dosage by one to two ounces every two weeks until you reach a daily dosage of three ounces.
4. Complete another copy of the Health Evaluation Questionnaire to help you decide which mangosteen dose to work with next based on your current level of health.
When your symptoms improve, it is important to reduce your daily dosages slowly. We have found when people with serious conditions reduce their amounts of a natural healing substance too quickly they may find not only that the symptoms return but that their body does not respond to the healing substance as effectively as it did before.
Reducing a dosage gradually is essential to give the body time to heal. Just because symptoms are reduced doesn't mean the underlying condition is healed. This can take time, and during that time, mangosteen's support can be invaluable.

INCLUDE the following notes when forwarding this Questionnaire to others:

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This "Health Evaluation Questionnaire" is adapted* from the book "Getting Started With Mangosteen" by Isa Navarre

*Dr. J. Frederic Templeman recommends taking Mangosteen juice WITH FOOD, up to a half hour before eating. The healing compounds of Mangosteen are enhanced when combined with some fat from food to "bind" with during digestion. Or, you can also take with the juice with another supplement that contains essential fatty acids.