1.
How do you feel today?
"Under
the Bed"
"Top
of the World"
2.
Energy Level:
"Chronic
Fatigue"
"Strong,
full of energy"
3.
Headaches:
Migraines:
No
more than once per year
Sinus:
No
more than once per year
Other:
No
more than once per year
4.
Aching Joints/Arthritis:
Presence
of arthritis (or ANY joint pain severe enough
to require prescription medication)
No
arthritis or joint pain
5.
Muscle Pain:
Chronic,
unexplained muscle pain, or diagnosed with fibromyalgia,
and/or requires taking prescription pain medications
at least twice a week
No
"chronic" muscle pain
6.
Menstrual Pain/PMS Symptoms/Mood Swings:
Severe
cycle-related mood swings, pain Chocolate cravings,
and/or severe PMS Symptoms virtually every month
Absence
of pain, mood swings or cravings related to menstrual
cycle
7.
Menopausal Symptoms:
Severe
hot flashes, dramatic mood swings, crying, etc.
No
menopause symptoms
8.
Sex Drive:
Really
not interested at all, or unable to perform at
a satisfactory level without prescription medications
Drive
and performance strong and vigorous
9.
Stress Management:
Easily
overwhelmed by small issues
Understand
and use healthy strategies to cope with stress
10.
Susceptibility to Colds and Other Viral Infections:
More
than 5 colds or viral infections per year
Very
rare occurrence (maybe 1 every few years)
11.
Concentration:
On
most days, I feel like my mind is in a "fog" all
the time
Always
awake and alert
12.
Memory:
Frequently
forgetful
Rarely
forget anything... Certainly nothing important
13.
Depression:
Have
been taking a prescription antidepressant for
over one year
Rarely
feel "down" and it never exceeds a few hours
14.
Sleep:
Difficulty
falling asleep more than 3 Nights per week OR
wake up (for No reason) 2 - 3 times per night
Fall
asleep easily and sleep soundly
15.
Food Cravings:
Uncontrollable
cravings almost daily
Cravings
are rare and easily controlled
16.
Bowel Movements - Patterns, Consistency, and Changes:
Stool
shifts from being constipated to diarrhea frequently
Soft,
easily passed stools are normal for me
17.
Bowel Movement - Frequency:
Always
constipated, no or less than one BM per week OR
Irritable Bowel Syndrome with frequent diarrhea
Two
or more soft, formed stools every day
18.
Bloating:
Severe,
after eating almost anything
Rarely,
if ever
19.
Heartburn/Indigestion:
Severe,
after most meals
Rarely,
if ever
20.
Cellulite:
Over
more than one large area of body (i.e., legs,
hips, arms)
None
21.
Allergies/Hay Fever:
Symptomatic
most of the time, unable to "pin down" the cause
to 1 or 2 things
No
allergies or allergy symptoms
22.
Strength and Muscle Tone:
Little
to no visible muscle, wasted look (even if overweight),
and/or strength strength is well below average
Extremely
well defined, visible muscles and/or strength
well above average
23.
Body Odor / Bad Breath:
Persistent,
almost daily problem
Rarely,
if ever
24.
Yeast / Fungus Infections:
Recurring
vaginal yeast infections constant uncontrollable
cravings for sweets, chronically tired and "achy"
Rarely,
if ever
25.
Urination:
Diagnosed
with benign prostatic hypertrophy (BHP), recurrent
bladder or kidney infections, or have chronic
problems when urinating
No
diagnosis of BPH, bladder / kidney infections
and/or urinating problems are an extremely rare
occurrence
26.
Do You Smoke?
27.
Number of caffeine-related drinks you consume per
day:
If
you drink more than 5, your score is 5
28.
Approximate number of pounds you need to lose to reach
your ideal weight:
29.
Number of warm-blooded pets you live with:
If
you live with more than 5, your score is 5
30.
Number of prescription, over-the-counter, or herbal/homeopathic-type
medications you take:
If
you take more than 5, your score is 5
31.
Indicate which of the following 10 types of medications
you are currently taking:
32.
Diseases/Conditions for which you are under a doctor's
care:
33.
Number of years you have been "sick":
How
did you hear about us?
(Please Select)
Internet
Nashville Diet Book
Television
Radio
Friend
Other (Please explain)
If
Other:
Additional
comments:
