Category I 0
1 2 3
Feeling that bowels do not empty completely
Lower
abdominal pain relief by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard
dry or small stool
Coated
tongue of "fuzzy" debris on tongue
Pass
large amount of foul smelling gas
More
than 3 bowel movements daily
Do you
use laxatives frequently
Category
II 0
1 2 3
Excessive
belching burping or bloating
Gas
immediately following a meal
Offensive
breath
Difficult
bowel movements
Sense of
fullness during and after meals
Difficulty
digesting fruits and vegetables;
Category
III 0
1 2 3
Stomach
pain, burning or aching 1- 4 hours after eating
Do you
frequently use antacids
Feeling
hungry an hour or two after eating
Heartburn
when lying down or bending forward
Temporary
relief from antacids, food,
Digestive
problems subside with rest and relaxation
Heartburn
due to spicy foods, chocolate, citrus,
Category
IV 0
1 2 3
Roughage and
fiber cause constipation
Indigestion
and fullness lasts 2-4 hours after eating
Pain,
tenderness, soreness on left side under rib cage bloated
Excessive
passage of gas
Nausea
and/or vomiting
Stool
undigested, foul smelling,
Frequent
urination
Increased
thirst and appetite
Difficulty
losing weight
Category
V 0
1 2 3
Greasy or
high fat foods cause distress
Lower bowel
gas and or bloating
Bitter
metallic taste in mouth,
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
Category
VI 0
1 2 3
Crave sweets
during the day
Irritable if
meals are missed
Depend on
coffee to keep yourself going or started
Get
lightheaded if meals are missed
Eating
relieves fatigue
Feel shaky,
jittery, tremors
Agitated,
easily upset, nervous
Poor memory,
forgetful
Blurred
vision
Category
VII 0
1 2 3
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 & appetite
Difficulty
losing weight
Category
VIII 0
1 2 3
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
IX 0
1 2 3
Cannot fall
asleep
Perspire
easily
Under high
amounts 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
X 0
1 2 3
Tired,
sluggish
Feel cold –
hands, feel, all over
Require
excessive amounts of sleep to function properly
Increase in
weight gain even with low-calorie diet
Gain weight
easily
Difficult,
infrequent bowel movements
Depression,
lack of motivation
Morning
headaches that wear off
Outer third
of eyebrow thins
Thinning of
hair on scalp, face or genitals or excessive falling hair
Dryness of
skin and/or scalp
Mental
sluggishness
Category
XI 0
1 2 3
Heart
palpations
Inward
trembling
Increased
pulse even at rest
Nervousness
and emotional
Insomnia
Night sweats
Difficulty
gaining weight
Category
XII 0
1 2 3
Diminished
sex drive
Menstrual
disorders of lack of menstruation
Increased
ability to eat sugars without symptoms
Category
XIII 0
1 2 3
Increased
sex drive
Tolerance to
sugars reduced
“Splitting”
type headaches
Category
XIV (Male Only) 0
1 2 3
Urination
difficulty or dribbling
Urination
frequent
Pain inside
of legs or heels
Feeling of
incomplete bowel evacuation
Leg
nervousness at night
Category
XV
(Male Only) 0
1 2 3
Decrease in
libido
Decrease in
spontaneous morning erections
Decrease in
fullness of erections
Difficulty
in maintain morning erections
Spells of
mental fatigue
Inability to
concentrate
Episodes of
depression
Muscle
soreness
Decrease in
physical stamina
Unexplained
weight gain
Increase in
fat distribution around chest and hips
Sweating
attacks
More
emotional then in the past
Category
XVI 0
1 2 3
Are you a
menopausal
Alternating
menstrual cycle lengths
Extended
menstrual cycle, greater than 32 days
Shortened
menses, less than every 24 days
0
1 2 3
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
breakouts
Facial hair
growth
Hair
loss/thinning
Category
XVII 0
1 2 3
How many
years have you been menopausal?
Do you ever
have uterine bleeding since menopause?
Hot flashes
Mental
fogginess
Disinterest
in sex
Mood swings
Depression
Painful
intercourse
Shrinking
breast
Facial hair
growth
Acne
Increased
vaginal, pain, dryness or itching
PART III
How many
alcohol beverages they consume per week?
How many
caffeinated beverages do you consume per day?
How many
times do you eat out per week?
How many
times a week do you eat raw nuts or seeds?
How many
times a week do you eat fish?
How many
times a week do you workout?
List the three worst foods you eat during the average week?
List the three healthiest foods you eat during the average
week?
Do you
smoke?
If yes, how
many times a day
a week
Rate your
stress levels on a scale of 1-10 during the average week.
Please list any medications you currently take and for what
conditions:
Please list any natural supplements you currently take and
for what conditions:
