Name
Invalid Input

Age
Invalid Input

Sex
Invalid Input

Date
Invalid Input

Part 1

Please list your 4 major health concerns in order of importance
Invalid Input

Part 2

Please select the appropriate number on all questions below.

0 as the least/never to 3 as the most/always.

Category 1

Feeling that bowels do not empty completely
Invalid Input

Lower abdominal pain relieved by passing stool or gas
Invalid Input

Alternating constipation and diarrhea
Invalid Input

Diarrhea
Invalid Input

Constipation
Invalid Input

Constipation Hard, dry, or small stool
Invalid Input

Coated tongue or “fuzzy” debris on tongue
Invalid Input

Pass large amount of foul-smelling gas
Invalid Input

More than 3 bowel movements daily
Invalid Input

Use laxatives frequently
Invalid Input

Category 2

Increasing frequency of food reactions
Invalid Input

Unpredictable food reactions
Invalid Input

Aches, pains, and swelling throughout the body
Invalid Input

Unpredictable abdominal swelling
Invalid Input

Frequent bloating and distention after eating
Invalid Input

Abdominal intolerance to sugars and starches
Invalid Input

Category 3

Intolerance to smells
Invalid Input

Intolerance to jewelry
Invalid Input

Intolerance to shampoo, lotion, detergents, etc
Invalid Input

Multiple smell and chemical sensitivities
Invalid Input

Constant skin outbreaks
Invalid Input

Category 4

Excessive belching, burping, or bloating
Invalid Input

Gas immediately following a meal
Invalid Input

Offensive breath
Invalid Input

Difficult bowel movements
Invalid Input

Sense of fullness during and after meals
Invalid Input

Difficulty digesting fruits and vegetables; undigested food found in stools
Invalid Input

Category 5

Stomach pain, burning, or aching 1-4 hours after eating
Invalid Input

Use of antacids
Invalid Input

Feel hungry an hour or two after eating
Invalid Input

Heartburn when lying down or bending forward
Invalid Input

Temporary relief by using antacids, food, milk, or carbonated beverages
Invalid Input

Digestive problems subside with rest and relaxation
Invalid Input

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
Invalid Input

Category 6

Roughage and fiber cause constipation
Invalid Input

Indigestion and fullness last 2-4 hours after eating
Invalid Input

Pain, tenderness, soreness on left side under rib cage
Invalid Input

Excessive passage of gas
Invalid Input

Nausea and/or vomiting
Invalid Input

Stool undigested, foul smelling, mucus like, greasy, or poorly formed
Invalid Input

Frequent urination
Invalid Input

Increased thirst and appetite
Invalid Input

Category 7

Greasy or high-fat foods cause distress
Invalid Input

Lower bowel gas and/or bloating several hours after eating
Invalid Input

Bitter metallic taste in mouth, especially in the morning
Invalid Input

Burpy, fishy taste after consuming fish oils
Invalid Input

Difficulty losing weight
Invalid Input

Unexplained itchy skin
Invalid Input

Yellowish cast to eyes
Invalid Input

Stool color alternates from clay colored to normal brown
Invalid Input

Reddened skin, especially palms
Invalid Input

Dry or flaky skin and/or hair
Invalid Input

History of gallbladder attacks or stones
Invalid Input

Have you had your gallbladder removed?
Invalid Input

Category 8

Acne and unhealthy skin
Invalid Input

Excessive hair loss
Invalid Input

Overall sense of bloating
Invalid Input

Bodily swelling for no reason
Invalid Input

Hormone imbalances
Invalid Input

Weight gain
Invalid Input

Poor bowel function
Invalid Input

Excessively foul-smelling sweat
Invalid Input

Category 9

Crave sweets during the day
Invalid Input

Irritable if meals are missed
Invalid Input

Depend on coffee to keep going/get started
Invalid Input

Get light-headed if meals are missed
Invalid Input

Eating relieves fatigue
Invalid Input

Feel shaky, jittery, or have tremors
Invalid Input

Agitated, easily upset, nervous
Invalid Input

Poor memory/forgetful
Invalid Input

Blurred vision
Invalid Input

Category 10

Fatigue after meals
Invalid Input

Crave sweets during the day
Invalid Input

Eating sweets does not relieve cravings for sugar
Invalid Input

Must have sweets after meals
Invalid Input

Waist girth is equal or larger than hip girth
Invalid Input

Frequent urination
Invalid Input

Increased thirst and appetite
Invalid Input

Difficulty losing weight
Invalid Input

Category 11

Cannot stay asleep
Invalid Input

Crave salt
Invalid Input

Slow starter in the morning
Invalid Input

Afternoon fatigue
Invalid Input

Dizziness when standing up quickly
Invalid Input

Afternoon headaches
Invalid Input

Headaches with exertion or stress
Invalid Input

Weak nails
Invalid Input

Category 12

Cannot fall asleep
Invalid Input

Perspire easily
Invalid Input

Under a high amount of stress
Invalid Input

Weight gain when under stress
Invalid Input

Wake up tired even after 6 or more hours of sleep
Invalid Input

Excessive perspiration or perspiration with little or no activity
Invalid Input

Category 13

Edema and swelling in ankles and wrists
Invalid Input

Muscle cramping
Invalid Input

Poor muscle endurance
Invalid Input

Frequent urination
Invalid Input

Frequent thirst
Invalid Input

Crave salt
Invalid Input

Abnormal sweating from minimal activity
Invalid Input

Alteration in bowel regularity
Invalid Input

Inability to hold breath for long periods
Invalid Input

Shallow, rapid breathing
Invalid Input

Category 14

Tired/sluggish
Invalid Input

Feel cold – hands, feet, all over
Invalid Input

Require excessive amounts of sleep to function properly
Invalid Input

Increase in weight even with low-calorie diet
Invalid Input

Gain weight easily
Invalid Input

Difficult, infrequent bowel movements
Invalid Input

Depression/lack of motivation
Invalid Input

Morning headaches that wear off as the day progresses
Invalid Input

Outer third of eyebrow thins
Invalid Input

Thinning of hair on scalp, face, or genitals, or excessive hair loss
Invalid Input

Dryness of skin and/or scalp
Invalid Input

Mental sluggishness
Invalid Input

Category 15

Heart palpitations
Invalid Input

Inward trembling
Invalid Input

Increased pulse even at rest
Invalid Input

Nervous and emotional
Invalid Input

Insomnia
Invalid Input

Night sweats
Invalid Input

Difficulty gaining weight
Invalid Input

Category 16 (Males Only)

Urination difficulty or dribbling
Invalid Input

Frequent urination
Invalid Input

Pain inside of legs or heels
Invalid Input

Feeling of incomplete bowel emptying
Invalid Input

Leg twitching at night
Invalid Input

Category 17 (Males Only)

Decreased libido
Invalid Input

Decreased number of spontaneous morning erections
Invalid Input

Decreased fullness of erections
Invalid Input

Difficulty maintaining morning erections
Invalid Input

Spells of mental fatigue
Invalid Input

Inability to concentrate
Invalid Input

Episodes of depression
Invalid Input

Muscle soreness
Invalid Input

Decreased physical stamina
Invalid Input

Unexplained weight gain
Invalid Input

Increase in fat distribution around chest and hips
Invalid Input

Sweating attacks
Invalid Input

More emotional than in the past
Invalid Input

Category 18 (Menstruating Females Only)

Perimenopausal
Invalid Input

Alternating menstrual cycle lengths
Invalid Input

Extended menstrual cycle (greater than 32 days)
Invalid Input

Shortened menstrual cycle (less than 24 days)
Invalid Input

Pain and cramping during periods
Invalid Input

Scanty blood flow
Invalid Input

Heavy blood flow
Invalid Input

Breast pain and swelling during menses
Invalid Input

Pelvic pain during menses
Invalid Input

Irritable and depressed during menses
Invalid Input

Acne
Invalid Input

Facial hair growth
Invalid Input

Hair loss/thinning
Invalid Input

Category 19 (Menopausal Females Only)

How many years have you been menopausal?
Invalid Input

Since menopause, do you ever have uterine bleeding?
Invalid Input

Hot flashes
Invalid Input

Mental fogginess
Invalid Input

Disinterest in sex
Invalid Input

Mood swings
Invalid Input

Depression
Invalid Input

Painful intercourse
Invalid Input

Shrinking breasts
Invalid Input

Facial hair growth
Invalid Input

Acne
Invalid Input

Increased vaginal pain, dryness, or itching
Invalid Input

Part 3

How many alcoholic beverages do you consume per week?
Invalid Input

Rate your stress level on a scale of 1-10 during the average week:
Invalid Input

How many caffeinated beverages do you consume per day?
Invalid Input

How many times do you eat fish per week?
Invalid Input

How many times do you eat out per week?
Invalid Input

How many times do you work out per week?
Invalid Input

How many times do you eat raw nuts or seeds per week?
Invalid Input

List the four worst foods you eat during the average week
Invalid Input

List the three healthiest foods you eat during the average week
Invalid Input

Part 4

Please list any medications you currently take and for what conditions
Invalid Input

Please list any natural supplements you currently take and for what conditions
Invalid Input

Copyright © 2019 Acuworks Health. All Rights Reserved.

×

Log in