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First Name |
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Last Name |
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Age |
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Sex |
Male
Female |
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Date |
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Part I |
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Please list your 5 major health
concerns in order of importance. |
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1. |
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2. |
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3. |
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4. |
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5. |
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Have you had your gallbladder
removed? Yes
No
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Are you perimenopausal? Yes
No
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Do you have alternating menstrual cycle
lengths? Yes
No
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Do you have an extended menstrual cycle,
greater than 32 days? Yes
No
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Do you have shortened menses, less than
every 24 days? Yes
No
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How many years have you been menopausal?
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Do you ever have uterine bleeding since
menopause? Yes
No
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Part II |
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Do you smoke? Yes
No
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If yes how many times a day:
times per week:
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| 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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Part III |
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Please pick the appropriate number on
all questions below. |
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1 never 2
sometimes 3 often 4 always
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Category I |
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1 |
2 |
3 |
4 |
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Feeling that the bowels do not empty
completely |
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Lower bowel relief by passing gas |
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Alternating constipation and diarrhea |
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Diarrhea |
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Constipation |
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Hard dry or small stool |
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Coated tongue of "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 II |
1 |
2 |
3 |
4 |
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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 foods found in stools |
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Category III |
1 |
2 |
3 |
4 |
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Stomach pain, burning or aching 1-4
hours after eating |
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Do you frequently use antacids |
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Feeling hungry an hour or two after
eating |
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Heartburn when lying down or bending
forward |
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Temporary relief from antacids, food,
milk 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 IV |
1 |
2 |
3 |
4 |
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Roughage and fiber cause constipation |
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Indigestion and fullness lasts 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,
mucous-like, greasy or poorly formed |
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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 V |
1 |
2 |
3 |
4 |
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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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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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Category VI |
1 |
2 |
3 |
4 |
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Crave sweets during the day |
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Irritable if meals are missed |
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Depend on coffee to keep yourself going
or started |
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Get lightheaded if meals are missed |
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Eating relieves fatigue |
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Feel shaky, jittery, 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 VII |
1 |
2 |
3 |
4 |
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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 & appetite |
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Difficulty losing weight |
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Category VIII |
1 |
2 |
3 |
4 |
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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 IX |
1 |
2 |
3 |
4 |
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Cannot fall asleep |
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Perspire easily |
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Under high amounts 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 X |
1 |
2 |
3 |
4 |
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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 gain 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 falling hair |
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Dryness of skin and/or scalp |
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Mental sluggishness |
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Category XI |
1 |
2 |
3 |
4 |
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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 XII |
1 |
2 |
3 |
4 |
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Diminished sex drive |
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Menstrual disorders or lack of
menstruation |
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Increased ability to eat sugars without
symptoms |
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Category XIII |
1 |
2 |
3 |
4 |
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Increased sex drive |
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Tolerance to sugars reduced |
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"Splitting" type headaches |
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Category XIV (Male Only) |
1 |
2 |
3 |
4 |
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Urination difficulty or dribbling |
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Urination frequent |
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Pain inside of legs or heels |
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Feeling of incomplete bowel
evacuation |
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Leg nervousness at night |
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Category XV (Males Only) |
1 |
2 |
3 |
4 |
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Decrease in libido |
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Decrease in spontaneous morning
erections |
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Decrease in fullness of erections |
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Difficulty in 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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Decrease in 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 past |
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Category XVI (Menstruating Females
Only) |
1 |
2 |
3 |
4 |
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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 break outs |
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Facial hair growth |
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Hair loss/thinning |
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Category XVII (Menopausal Females
Only) |
1 |
2 |
3 |
4 |
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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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