Questionnaire

Digestion/Absorption


YES NO

Does food feel like it sits in your stomach a long time?


YES NO

Does food seem to mal-digest, cause nausea, cramps or heartburn?


YES NO

Do you have problems with frequent constipation or diarrhea?

Dysbiosis of the Stomach


YES NO

Did you ever suffer diarrhea, upset stomach or vaginitis from antibiotics?


YES NO

Do you suffer from regular bloating or gas?


YES NO

Do you have brain fog or fatigue after eating?

Nutritional Status


YES NO

Are you overweight or obese?


YES NO

Do you eat fast foods more the once per week?


YES NO

Do you NOT eat in 5 servings of fruit and vegetables every day?

Vitamin Deficiency


YES NO

Do you suffer from leg cramps at night?


YES NO

Do you feel chronically fatigued?


YES NO

Do you have a history of precancerous or cancerous lesions?

Liver/Gallbladder


YES NO

Do you get loose stool after eating fatty foods?


YES NO

Do you wake up with coated tongue or bad breath?


YES NO

Are you sensitive to perfumes, tobacco or fresh paint?

Thyroid Insufficiency


YES NO

Do you feel unusually chilly or seem cold from time to time?


YES NO

Is your skin dry and/or is your hair dry and brittle?


YES NO

Are you gaining weight without cause or not able to lose weight when trying to?

Adrenal Insufficiency


YES NO

Do you sometimes get dizzy when you stand up too quickly?


YES NO

Do you have problems with low blood sugar and/or feel shaky or sweaty?


YES NO

Have you been working long hours, and/or experiencing significant stress for a long time?

Neurotransmitter Imbalance / Connective Tissue


YES NO

Do you have a history of, or current problems with, anxiety or panic attacks?


YES NO

Do you have a history of, or current problems with, depression?


YES NO

Do you have problems relaxing and falling asleep quickly?

Dysglycemia


YES NO

Is your fasting blood sugar over 100?


YES NO

Has your physician diagnosed you with pre-diabetes or diabetes?


YES NO

Do you have excess weight around your abdomen?

Food Allergies


YES NO

Do you suffer from chronic nasal congestion and post nasal drip?


YES NO

Do you suffer from irritable bowel—constant upset intestines?


YES NO

Do you suffer from asthma, eczema, psoriasis, migraines, or an auto-immune disease?

Hormone Imbalance


YES NO

Do you have any problems with your periods—too long, too heavy, too painful?


YES NO

Do you have a significant loss of libido?


YES NO

Do you have problem building muscles?

Joint/Muscle Inflammation


YES NO

Do you wake up with stiff joints?


YES NO

Do you have to limit your activity due to joint or muscle pains?


YES NO

Do you have swelling of any joints?

Lipid Metabolism


YES NO

Do you have high cholesterol or LDL cholesterol?


YES NO

Do you have high triglycerides


YES NO

Do you have low HDLs?

Cardiovascular


YES NO

Do you have high blood pressure?


YES NO

Do you smoke?


YES NO

Do you NOT exercise regularly several times a week?

Kidneys/Bladder


YES NO

Do you have chronic irritation in your bladder—urgency to go or low urine stream?


YES NO

Do you have a history of kidney stones?


YES NO

Is your urine generally very dark colored?