Metabolic Assessment Form™

Metabolic Assessment Form™

Please select who will be participating...

Adult Minor(s)
1 Minor 2 Minors 3 Minors 4 Minors 5 Minors More Minors 6 Minors 7 Minors 8 Minors 9 Minors 10 Minors

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First Participant's Name

First Name*

Last Name*

Select Gender

First Participant's Age Acknowledgment*

First Participant's Date of Birth*

Date of Birth

I certify that I am 18 years of age or older

First Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

First Participant's Signature*

Type Signature

Draw Signature

Change Font

Accept Signature Clear

Click to Sign

Edit Signature

Second Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Second Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Third Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Third Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Fourth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Fourth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Fifth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Fifth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Sixth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Sixth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Seventh Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Seventh Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Eighth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Eighth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Ninth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Ninth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Tenth Participant's Name

First Name*

Last Name*

Select Gender

Participant's Date of Birth*

Date of Birth

Tenth Participant's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Parent or Guardian's Email Address

Email*

Confirm Email*

Check to receive information, news, and discounts by e-mail.

Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.

Parent or Guardian's Name

First Name*

Last Name*

Phone*

Select Gender

Parent or Guardian's Age Acknowledgment*

Parent or Guardian's Date of Birth*

Date of Birth

I certify that I am 18 years of age or older

Parent or Guardian's Information

Age

PART I - Please list your 5 major health concerns in order of importance:

PART II - Please choose the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely *

Lower abdominal pain relieved by passing stool or gas*

Alternating constipation and diarrhea *

Diarrhea*

Constipation*

Hard, dry, or small stool *

Coated tongue or "fuzzy" debris on tongue *

Pass large amount of foul-smelling gas *

More than 3 bowel movements daily *

Use laxatives frequently *

Category II

Increasing frequency of food reactions *

Unpredictable food reactions *

Aches, pains, and swelling throughout the body*

Unpredictable abdominal swelling *

Frequent bloating and distention after eating *

Category III

Intolerance to smells *

Intolerance to jewelry *

Intolerance to shampoo, lotion, detergents, etc *

Multiple smell and chemical sensitivities *

Constant skin outbreaks *

Category IV

Excessive belching, burping, or bloating *

Gas immediately following a meal *

Offensive breath *

Difficult bowel movements *

Sense of fullness during and after meals *

Difficulty digesting proteins and meats; undigested food found in stools *

Category V

Stomach pain, burning, or aching 1-4 hours after eating*

Use of antacids *

Feel hungry an hour or two after eating *

Heartburn when lying down or bending forward*

Temporary relief by using antacids, food, milk, or carbonated beverages *

Digestive problems subside with rest and relaxation*

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine *

Category VI

Difficulty digesting roughage and fiber *

Indigestion and fullness last 2-4 hours after eating*

Pain, tenderness, soreness on left side under rib cage*

Excessive passage of gas *

Nausea and/or vomiting *

Stool undigested, foul smelling, mucus like, greasy, or poorly formed *

Frequent loss of appetite *

Category VII

Abdominal distention after consumption of fiber, starches, and sugar*

Abdominal distention after certain probiotic or natural supplements*

Decreased gastrointestinal motility, constipation*

Increased gastrointestinal motility, diarrhea*

Alternating constipation and diarrhea*

Suspicion of nutritional malabsorption*

Frequent use of antacid medication*

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/Diverticulitis, or Leaky Gut Syndrome?*

Yes

Category VIII

Greasy or high-fat foods cause distress*

Lower bowel gas and/or bloating several hours after eating*

Bitter metallic taste in mouth, especially in the morning*

Burpy, fishy taste after consuming fish oils*

Unexplained itchy skin*

Yellowish cast to eyes*

Stool color alternates from clay colored to normal brown*

Reddened skin, especially palms*

Dry or flaky skin and/or hair*

History of gallbladder attacks or stones*

Have you had your gallbladder removed?*

Yes

Category IX

Acne and unhealthy skin*

Excessive hair loss*

Overall sense of bloating*

Bodily swelling for no reason*

Hormone imbalances*

Weight gain*

Poor bowel function*

Excessively foul-smelling sweat*

Category X

Crave sweets during the day*

Irritable if meals are missed*

Depend on coffee to keep going/get started*

Get light-headed if meals are missed*

Eating relieves fatigue*

Feel shaky, jittery, or have tremors*

Agitated, easily upset, nervous*

Poor memory, forgetful between meals*

Blurred vision*

Category XI

Fatigue after meals*

Crave sweets during the day*

Eating sweets does not relieve cravings for sugar*

Must have sweets after meals*

Waist girth is equal or larger than hip girth*

Frequent urination*

Increased thirst and appetite*

Difficulty losing weight*

Category XII

Cannot stay asleep*

Crave salt*

Slow starter in the morning*

Afternoon fatigue*

Dizziness when standing up quickly*

Afternoon headaches*

Headaches with exertion or stress*

Weak nails*

Category XIII

Cannot fall asleep*

Perspire easily*

Under a high amount of stress*

Weight gain when under stress*

Wake up tired even after 6 or more hours of sleep*

Excessive perspiration or perspiration with little or no activity*

Category XIV

Edema and swelling in ankles and wrists*

Muscle cramping*

Poor muscle endurance*

Frequent urination*

Frequent thirst*

Crave salt*

Abnormal sweating from minimal activity*

Alteration in bowel regularity*

Inability to hold breath for long periods*

Shallow, rapid breathing*

Category XV

Tired/sluggish*

Feel cold-hands, feet, all over*

Require excessive amounts of sleep to function properly*

Increase in weight even with low-calorie diet*

Gain weight easily*

Difficult, infrequent bowel movements*

Depression/lack of motivation*

Morning headaches that wear off as the day progresses*

Outer third of eyebrow thins*

Thinning of hair on scalp, face, or genitals, or excessive hair loss*

Dryness of skin and/or scalp*

Mental sluggishness*

Category XVI

Heart palpitations*

Inward trembling*

Increased pulse even at rest*

Nervous and emotional*

Insomnia*

Night sweats*

Difficulty gaining weight*

Category XVII (Males Only)

Urination difficulty or dribbling*

Frequent urination*

Pain inside of legs or heels*

Feeling of incomplete bowel emptying*

Leg twitching at night*

Category XVIII (Males Only)

Decreased libido*

Decreased number of spontaneous morning erections*

Decreased fullness of erections*

Difficulty maintaining morning erections*

Spells of mental fatigue*

Inability to concentrate*

Episodes of depression*

Muscle soreness*

Decreased physical stamina*

Unexplained weight gain*

Increase in fat distribution around chest and hips*

Sweating attacks*

More emotional than in the past*

Category XIX (Menstruating Females Only)

Perimenopausal*

Yes

Alternating menstrual cycle lengths*

Yes

Extended menstrual cycle (greater than 32 days)*

Yes

Shortened menstrual cycle (less than 24 days)*

Yes

Pain and cramping during periods*

Scanty blood flow*

Heavy blood flow*

Breast pain and swelling during menses*

Pelvic pain during menses*

Irritable and depressed during menses*

Acne*

Facial hair growth*

Hair loss/thinning*

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?*

Yes

Hot flashes*

Mental fogginess*

Disinterest in sex*

Mood swings*

Depression*

Painful intercourse*

Shrinking breasts*

Facial hair growth*

Acne*

Increased vaginal pain, dryness, or itching*

PART III

How many alcoholic beverages do you consume per week?

How many caffeinated beverages do you consume per day?

How many times do you eat out per week?

How many times do you eat raw nuts or seeds per week?

List the three worst foods you eat during the average week:

List the three healthiest foods you eat during the average week:

Rate your stress level on a scale of 1-10 during the average week:

How many times do you eat fish per week?

How many times do you work out per week?

PART IV

Please list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Parent or Guardian's Signature*

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