Name:(first, last) Age: General Fatigue or weakness Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Difficulty losing weight Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Frequent illness/infections Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often High stress lifestyle Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Smoking Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Drink more than 2 cups of coffee/day Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Bad breath and /or body odour Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Constipation Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Bags under eyes Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Crave sugars, bread, alcohol Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Difficulty digesting certain foods Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Have used antibiotics in past 10 years Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Allergies Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Poor concentration or memory Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Belching or burping after meals Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Skin/complexion problems Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Frequent consumption of red meat Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Regular use of dairy products Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Heavy alcohol consumption Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Exposure to toxins/chemicals Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Frequent mood swings Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Depressed and/or irritable Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Brittle fingernails Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Dry, brittle hair, split ends Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often High fat/high cholesterol diet Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Nervousness/anxiety/tension/worry Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Insomian/restless sleep Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Low fiber diet Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Muscle cramps Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Sleepy when sitting up Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Female: menstraul cramps Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Bronchitis/asthma/pneumonia/emphysema Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Cellulite Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Cold hands and feet Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Varicose veins Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Feeling out of control Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Food/chemical sensitivities Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Frequent yeast/fungus problems Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Bones break easily, ostereoporis Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Too little exercise Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Excessive mucous Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Short of breath climbing stairs Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Tingling in lips, fingers, arms, legs Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Chest pains Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Very rapid or slow heart beat Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Painful, hard or thin bowel movements Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Alternating constipation/diarrhea Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Recurrent bladder infections Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Female: Menopause, hot flashes Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Female: PMS Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Difficult urination Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Swollen glands, puffy throat Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Lower abdominal pain Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Frequent need to urinate Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Joint Pain Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Sinus inflammation/discharge Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Arthritis Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Sudden weight gain/loss Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Headache/Migraines Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Female: Taking birth control pills Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Lower back pains Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Dry, flaky skin Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Drink less than 6 glasses of fluids/day Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Water retention Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Low sex drive Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Feeling heavy/bloated after meals Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often Chronic Cough Not Applicable 1 - mild/rarely 2 - moderate/regularly 3 - severe/often
