Name
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Age
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Sex
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Date
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Part 1

Please list your 4 major health concerns in order of importance
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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
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Lower abdominal pain relieved by passing stool or gas
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Alternating constipation and diarrhea
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Diarrhea
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Constipation
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Constipation Hard, dry, or small stool
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Coated tongue or “fuzzy” debris on tongue
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Pass large amount of foul-smelling gas
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More than 3 bowel movements daily
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Use laxatives frequently
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Category 2

Increasing frequency of food reactions
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Unpredictable food reactions
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Aches, pains, and swelling throughout the body
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Unpredictable abdominal swelling
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Frequent bloating and distention after eating
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Abdominal intolerance to sugars and starches
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Category 3

Intolerance to smells
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Intolerance to jewelry
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Intolerance to shampoo, lotion, detergents, etc
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Multiple smell and chemical sensitivities
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Constant skin outbreaks
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Category 4

Excessive belching, burping, or bloating
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Gas immediately following a meal
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Offensive breath
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Difficult bowel movements
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Sense of fullness during and after meals
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Difficulty digesting fruits and vegetables; undigested food found in stools
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Category 5

Stomach pain, burning, or aching 1-4 hours after eating
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Use of antacids
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Feel hungry an hour or two after eating
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Heartburn when lying down or bending forward
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Temporary relief by using antacids, food, milk, or carbonated beverages
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Digestive problems subside with rest and relaxation
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Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
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Category 6

Roughage and fiber cause constipation
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Indigestion and fullness last 2-4 hours after eating
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Pain, tenderness, soreness on left side under rib cage
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Excessive passage of gas
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Nausea and/or vomiting
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Stool undigested, foul smelling, mucus like, greasy, or poorly formed
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Frequent urination
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Increased thirst and appetite
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Category 7

Greasy or high-fat foods cause distress
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Lower bowel gas and/or bloating several hours after eating
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Bitter metallic taste in mouth, especially in the morning
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Burpy, fishy taste after consuming fish oils
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Difficulty losing weight
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Unexplained itchy skin
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Yellowish cast to eyes
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Stool color alternates from clay colored to normal brown
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Reddened skin, especially palms
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Dry or flaky skin and/or hair
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History of gallbladder attacks or stones
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Have you had your gallbladder removed?
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Category 8

Acne and unhealthy skin
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Excessive hair loss
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Overall sense of bloating
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Bodily swelling for no reason
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Hormone imbalances
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Weight gain
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Poor bowel function
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Excessively foul-smelling sweat
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Category 9

Crave sweets during the day
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Irritable if meals are missed
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Depend on coffee to keep going/get started
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Get light-headed if meals are missed
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Eating relieves fatigue
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Feel shaky, jittery, or have tremors
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Agitated, easily upset, nervous
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Poor memory/forgetful
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Blurred vision
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Category 10

Fatigue after meals
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Crave sweets during the day
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Eating sweets does not relieve cravings for sugar
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Must have sweets after meals
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Waist girth is equal or larger than hip girth
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Frequent urination
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Increased thirst and appetite
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Difficulty losing weight
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Category 11

Cannot stay asleep
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Crave salt
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Slow starter in the morning
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Afternoon fatigue
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Dizziness when standing up quickly
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Afternoon headaches
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Headaches with exertion or stress
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Weak nails
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Category 12

Cannot fall asleep
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Perspire easily
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Under a high amount of stress
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Weight gain when under stress
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Wake up tired even after 6 or more hours of sleep
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Excessive perspiration or perspiration with little or no activity
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Category 13

Edema and swelling in ankles and wrists
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Muscle cramping
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Poor muscle endurance
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Frequent urination
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Frequent thirst
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Crave salt
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Abnormal sweating from minimal activity
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Alteration in bowel regularity
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Inability to hold breath for long periods
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Shallow, rapid breathing
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Category 14

Tired/sluggish
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Feel cold – hands, feet, all over
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Require excessive amounts of sleep to function properly
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Increase in weight even with low-calorie diet
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Gain weight easily
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Difficult, infrequent bowel movements
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Depression/lack of motivation
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Morning headaches that wear off as the day progresses
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Outer third of eyebrow thins
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Thinning of hair on scalp, face, or genitals, or excessive hair loss
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Dryness of skin and/or scalp
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Mental sluggishness
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Category 15

Heart palpitations
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Inward trembling
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Increased pulse even at rest
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Nervous and emotional
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Insomnia
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Night sweats
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Difficulty gaining weight
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Category 16 (Males Only)

Urination difficulty or dribbling
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Frequent urination
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Pain inside of legs or heels
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Feeling of incomplete bowel emptying
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Leg twitching at night
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Category 17 (Males Only)

Decreased libido
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Decreased number of spontaneous morning erections
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Decreased fullness of erections
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Difficulty maintaining morning erections
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Spells of mental fatigue
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Inability to concentrate
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Episodes of depression
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Muscle soreness
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Decreased physical stamina
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Unexplained weight gain
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Increase in fat distribution around chest and hips
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Sweating attacks
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More emotional than in the past
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Category 18 (Menstruating Females Only)

Perimenopausal
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Alternating menstrual cycle lengths
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Extended menstrual cycle (greater than 32 days)
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Shortened menstrual cycle (less than 24 days)
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Pain and cramping during periods
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Scanty blood flow
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Heavy blood flow
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Breast pain and swelling during menses
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Pelvic pain during menses
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Irritable and depressed during menses
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Acne
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Facial hair growth
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Hair loss/thinning
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Category 19 (Menopausal Females Only)

How many years have you been menopausal?
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Since menopause, do you ever have uterine bleeding?
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Hot flashes
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Mental fogginess
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Disinterest in sex
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Mood swings
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Depression
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Painful intercourse
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Shrinking breasts
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Facial hair growth
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Acne
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Increased vaginal pain, dryness, or itching
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Part 3

How many alcoholic beverages do you consume per week?
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Rate your stress level on a scale of 1-10 during the average week:
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How many caffeinated beverages do you consume per day?
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How many times do you eat fish per week?
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How many times do you eat out per week?
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How many times do you work out per week?
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How many times do you eat raw nuts or seeds per week?
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List the four worst foods you eat during the average week
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List the three healthiest foods you eat during the average week
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Part 4

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