PART I Please list your 5 major health concerns in order of importance:
PART II Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.
0123 Feeling that bowels do not empty completely 0123 Lower abdominal pain relieved by passing stool or gas 0123 Alternating constipation and diarrhea 0123 Diarrhea 0123 Constipation 0123 Hard, dry, or small stool 0123 Coated tongue or "fuzzy" debris on tongue 0123 Pass large amount of foul-smelling gas 0123 More than 3 bowel movements daily 0123 Use laxatives frequently
0123 Increasing frequency of food reactions 0123 Unpredictable food reactions 0123 Aches, pains, and swelling throughout the body 0123 Unpredictable abdominal swelling 0123 Frequent bloating and distention after eating 0123 Abdominal intolerance to sugars and starches
0123 Intolerance to smells 0123 Intolerance to jewelry 0123 Intolerance to shampoo, lotion, detergents, etc. 0123 Multiple smell and chemical sensitivities 0123 Constant skin outbreaks
0123 Excessive belching, burping, or bloating 0123 Gas immediately following a meal 0123 Offensive breath 0123 Difficult bowel movement 0123 Sense of fullness during and after meals 0123 Difficulty digesting fruits and vegetables; undigested food found in stools
0123 Stomach pain, burning, or aching 1-4 hours after eating 0123 Use antacids 0123 Feel hungry an hour or two after eating 0123 Heartburn when lying down or bending forward 0123 Temporary relief by using antacids, food, milk, or carbonated beverages 0123 Digestive problems subside with rest and relaxation 0123 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
0123 Roughage and fiber cause constipation 0123 Indigestion and fullness last 2-4 hours after eating 0123 Pain, tenderness, soreness on left side under rib cage 0123 Excessive passage of gas 0123 Nausea and/or vomiting 0123 Stool undigested, foul smelling, mucous like, greasy, or poorly formed 0123 Frequent urination 0123 Increased thirst and appetite
0123 Greasy or high-fat foods cause distress 0123 Lower bowel gas and/or bloating several hours after eating 0123 Bitter metallic taste in mouth, especially in the morning 0123 Burpy, fishy taste after consuming fish oils 0123 Difficulty losing weight 0123 Unexplained itchy skin 0123 Yellowish cast to eyes 0123 Stool color alternates from clay colored to normal brown 0123 Reddened skin, especially palms 0123 Dry or flaky skin and/or hair 0123 History of gallbladder attacks or stones YesNo Have you had your gallbladder removed?
0123 Acne and unhealthy skin 0123 Excessive hair loss 0123 Overall sense of bloating 0123 Bodily swelling for no reason 0123 Hormone imbalances 0123 Weight gain 0123 Poor bowel function 0123 Excessively foul-smelling sweat
0123 Crave sweets during the day 0123 Irritable if meals are missed 0123 Depend on coffee to keep going/get started 0123 Get light-headed if meals are missed 0123 Eating relieves fatigue 0123 Feel shaky, jittery, or have tremors 0123 Agitated, easily upset, nervous 0123 Poor memory/forgetful 0123 Blurred vision
0123 Fatigue after meals 0123 Crave sweets during the day 0123 Eating sweets does not relieve cravings for sugar 0123 Must have sweets after meals 0123 Waist girth is equal or larger than hip girth 0123 Frequent urination 0123 Increased thirst and appetite 0123 Difficulty losing weight
0123 Cannot stay asleep 0123 Crave salt 0123 Slow starter in the morning 0123 Afternoon fatigue 0123 Dizziness when standing up quickly 0123 Afternoon headaches 0123 Headaches with exertion or stress 0123 Weak nails *** Make sure you complete the questions in the right column. ***
0123 Cannot fall asleep 0123 Perspire easily 0123 Under high amount of stress 0123 Weight gain when under stress 0123 Wake up tired even after 6 or more hours of sleep 0123 Excessive perspiration or perspiration with little or no activity
0123 Edema and swelling in ankles and wrists 0123 Muscle cramping 0123 Poor muscle endurance 0123 Frequent urination 0123 Frequent thirst 0123 Crave salt 0123 Abnormal sweating from minimal activity 0123 Alteration in bowel regularity 0123 Inability to hold breath for long periods 0123 Shallow, rapid breathing
0123 Tired/sluggish 0123 Feel cold?hands, feet, all over 0123 Require excessive amounts of sleep to function properly 0123 Increase in weight even with low-calorie diet 0123 Gain weight easily 0123 Difficult, infrequent bowel movements 0123 Depression/lack of motivation 0123 Morning headaches that wear off as the day progresses 0123 Outer third of eyebrow thins 0123 Thinning of hair on scalp, face, or genitals, or excessive hair loss 0123 Dryness of skin and/or scalp 0123 Mental sluggishness
0123 Heart palpitations 0123 Inward trembling 0123 Increased pulse even at rest 0123 Nervous and emotional 0123 Insomnia 0123 Night sweats 0123 Difficulty gaining weight
0123 Diminished sex drive 0123 Menstrual disorders or lack of menstruation 0123 Increased ability to eat sugars without symptoms
0123 Increased sex drive 0123 Tolerance to sugars reduced 0123 "Splitting" - type headaches
---MaleFemale - MenstruatingFemale - Menopausal
0123 Urination difficulty or dribbling 0123 Frequent urination 0123 Pain inside of legs or heels 0123 Feeling of incomplete bowel emptying 0123 Leg twitching at night
0123 Decreased libido 0123 Decreased number of spontaneous morning erections 0123 Decreased fullness of erections 0123 Difficulty maintaining morning erections 0123 Spells of mental fatigue 0123 Inability to concentrate 0123 Episodes of depression 0123 Muscle soreness 0123 Decreased physical stamina 0123 Unexplained weight gain 0123 Increase in fat distribution around chest and hips 0123 Sweating attacks 0123 More emotional than in the past
YesNo Perimenopausal YesNo Alternating menstrual cycle lengths YesNo Extended menstrual cycle (greater than 32 days) YesNo Shortened menstrual cycle (less than 24 days) 0123 Pain and cramping during periods 0123 Scanty blood flow 0123 Heavy blood flow 0123 Breast pain and swelling during menses 0123 Pelvic pain during menses 0123 Irritable and depressed during menses 0123 Acne 0123 Facial hair growth 0123 Hair loss/thinning
How many years have you been menopausal? YesNo Since menopause, do you ever have uterine bleeding? 0123 Hot flashes 0123 Mental fogginess 0123 Disinterest in sex 0123 Mood swings 0123 Depression 0123 Painful intercourse 0123 Shrinking breasts 0123 Facial hair growth 0123 Acne 0123 Increased vaginal pain, dryness, or itching
PART III
PART IV
Please fill out the following form in as much detail as possible. All your health information is kept confidential.