Name *

First Name

Last Name

Abdominal pain *

0

1

2

Abnormal reactions to certain foods *

0

1

2

Addicted to cofee with sugar and/or colas *

0

1

2

Alcohol consumption makes you feel sick *

0

1

2

Allergies *

0

1

2

Antacid use, such as Tums *

0

1

2

Anxiety *

0

1

2

Arthritis *

0

1

2

Asthma *

0

1

2

Atypical addiction to a negative point of view *

0

1

2

Bad breath *

0

1

2

Bed wetting *

0

1

2

Belching *

0

1

2

Bladder infections *

0

1

2

Bloating *

0

1

2

Blurry, unclear vision *

0

1

2

Bone loss *

0

1

2

Bowel disease (e.g. IBS, IBD, Crohn's etc...) *

0

1

2

Bowel urgency, occasional accidents *

0

1

2

Brain fog *

0

1

2

Bronchitis *

0

1

2

Bruise easily *

0

1

2

Chronic inflammation *

0

1

2

Cold hands & feet *

0

1

2

Confusion *

0

1

2

Constipation *

0

1

2

Chronic cough or recurrent bronchitis *

0

1

2

Crave alcoholic beverages *

0

1

2

Crave sugar, bread, or other foods *

0

1

2

Cruciferous vegetables cause bloating/gas *

0

1

2

Damp/muggy weather or moldy places make your symptoms worse *

0

1

2

Dark circles under eyes *

0

1

2

Decline in your sense of wellbeing *

0

1

2

Decreased problem-solving ability *

0

1

2

Decreased sweating *

0

1

2

Depression *

0

1

2

Diarrhea *

0

1

2

Difficulty losing weight *

0

1

2

Difficulty making decisions *

0

1

2

Difficulty setting goals *

0

1

2

Discoloration of your armpits (darker & thicker than your normal skin) *

0

1

2

Dizziness/loss of balance *

0

1

2

Do you feel you should eat a healthier diet? *

0

1

2

Drooling while asleep *

0

1

2

Droopy breasts or lessening in volume *

0

1

2

Drowsiness *

0

1

2

Dry eyes or skin *

0

1

2

Dry lips during the day, damp at night *

0

1

2

Dry skin and/or hair *

0

1

2

Dysglycemia *

0

1

2

Easily disrupted sleep *

0

1

2

Eat in a rush *

0

1

2

Eat in front of screens (e.g. tv, computer, phone, etc..) *

0

1

2

Eat lightly cooked pork products *

0

1

2

Eat sushi/sashimi *

0

1

2

Elevated cholesterol *

0

1

2

Endometriosis *

0

1

2

Epilepsy *

0

1

2

Excess body odour *

0

1

2

Excess hair on face, chest, arms *

0

1

2

Excess sweating *

0

1

2

Excessively aggressive *

0

1

2

Ankle swelling *

0

1

2

Exposure to perfumes, insecticides, fabric softener odours, or other chemicals provoke reactions *

0

1

2

Fainting spells *

0

1

2

Family history of thyroid problems *

0

1

2

Fatigue *

0

1

2

Fats/greasy foods cause nausea/headaches *

0

1

2

Feel full after eating a heavy meal *

0

1

2

Feel warm/flushed at room temperature *

0

1

2

Feeling "spacey" *

0

1

2

Fevers of unknown origins *

0

1

2

Fibrocystic breast disease *

0

1

2

Fibromyalgia *

0

1

2

Flatulence *

0

1

2

Fluid retention *

0

1

2

Food allergies/sensitivities *

0

1

2

Food, hair, body odour not relieved by washing *

0

1

2

Forgetfulness *

0

1

2

Foul smelling stool *

0

1

2

Frequent bowel movements *

0

1

2

Frequent cold and/or flu *

0

1

2

Frequent cold sores or fever blisters *

0

1

2

Frequent occurrence of stomach bugs *

0

1

2

Frequent urination (especially at night) *

0

1

2

Frequently experience a runny or stuffy nose *

0

1

2

Gallbladder problems or removal *

0

1

2

Gastritis, gastric ulcers *

0

1

2

GERD (gastroesophageal reflux disease) *

0

1

2

Glucose intolerance *

0

1

2

Go barefoot in parks, streets *

0

1

2

Greasy skin and/or hair *

0

1

2

Grinding teeth while asleep *

0

1

2

Hair loss (head or body) *

0

1

2

Hands shake or tremble *

0

1

2

Has experienced athlete's foot, ringworm, "jock itch" or other chronic fungus infections or the skin/nails *

0

1

2

Has experienced persistent prostatitis, vaginitis, or other problems affecting the reproductive organs *

0

1

2

Has previously taken cortisone-type drugs *

0

1

2

Has taken a broad spectrum antibiotic drug (even for a short period) *

0

1

2

Has taken antibiotics more than twice this year *

0

1

2

Has taken or takes birth control pills *

0

1

2

Has taken tetracyclines (Sumycin, Panmycin, Vibramycin, Minocin, etc...) or other antibiotics for acne for 1 month or longer *

0

1

2

Hayfever or airborne allergies *

0

1

2

Recurring headaches *

0

1

2

Heart pain *

0

1

2

Heart palpitations *

0

1

2

Heartburn, indigestion, Acid reflux *

0

1

2

Heavy periods with clotting *

0

1

2

Hemorrhoids *

0

1

2

Hiatal hernia *

0

1

2

High blood pressure *

0

1

2

High cholesterol *

0

1

2

High stress levels *

0

1

2

History of giardia, pin worms, worms *

0

1

2

Hives *

0

1

2

Hot flashes *

0

1

2

Hungry after meals *

0

1

2

Hungry up to 3 hours after eating *

0

1

2

Impotence *

0

1

2

Inability to gain muscle despite regular weight training *

0

1

2

Increased appetite *

0

1

2

Infertility *

0

1

2

Insomnia *

0

1

2

Insufficient chewing *

0

1

2

Intestinal cramps, burning *

0

1

2

Iron deficiency/Anemia *

0

1

2

Irritable *

0

1

2

Irritable if late to eat or meal is skipped *

0

1

2

Itchy mouth or throat *

0

1

2

Itchy or restless legs (especially at night) *

0

1

2

Itchy, watery or red eyes *

0

1

2

Jaundice *

0

1

2

Kiss pets, allow them to lick your face *

0

1

2

Lack of drive/motivation *

0

1

2

Lack of initiative *

0

1

2

Leaky or over-active bladder *

0

1

2

Less assertive *

0

1

2

Lethargy *

0

1

2

Long-term aspirin use *

0

1

2

Longitudinal striations on fingernails *

0

1

2

Loose stools, alternating with constipation *

0

1

2

Lose temper easily *

0

1

2

Losing weight without trying *

0

1

2

Loss of appetite *

0

1

2

Loss of interest in exercise *

0

1

2

Loss of muscle mass, strength or tone *

0

1

2

Loss of voice, laryngitis *

0

1

2

Low blood pressure *

0

1

2

Low body temperature (below the normal 98.6) *

0

1

2

Low energy in the afternoon (2-5pm) *

0

1

2

Low libido *

0

1

2

Men: sexual dysfunction *

0

1

2

Menstrual problems (e.g. cramps, short/long cycles, etc...) *

0

1

2

Midnight snacking *

0

1

2

Migraines *

0

1

2

Miscarriage in first trimester *

0

1

2

Mood swings *

0

1

2

More than one miscarriage *

0

1

2

Mucus or blood in stool *

0

1

2

Muscle aches *

0

1

2

Muscle cramps *

0

1

2

Muscle weakness *

0

1

2

Nasal congestion *

0

1

2

Nasal itching *

0

1

2

Nausea after taking supplements *

0

1

2

Nausea, vomiting *

0

1

2

Need for extra sleep, wake feeling tired *

0

1

2

Nervous behaviour, hyperactivity *

0

1

2

Night sweats *

0

1

2

Nosebleeds *

0

1

2

Numbness, tingling in hands/feet *

0

1

2

Ovarian, breast, or endometrial cysts *

0

1

2

Pain and/or swelling of joints *

0

1

2

Pain in umbilicus *

0

1

2

Pain: back, thighs, shoulders *

0

1

2

Painful periods *

0

1

2

Painful sex *

0

1

2

Panic attacks *

0

1

2

Pasty, pale or puffy skin *

0

1

2

Periods of blurred vision *

0

1

2

Picking/boring at nose *

0

1

2

Poor concentration *

0

1

2

Poor coordination *

0

1

2

Poor memory *

0

1

2

Premenstrual breast tenderness *

0

1

2

Premenstrual fluid retention/weight gain *

0

1

2

Premenstrual headaches *

0

1

2

Premenstrual mood swings *

0

1

2

Premenstrual tension *

0

1

2

Previously diagnosed with an autoimmune disease or condition *

0

1

2

Protruding tongue *

0

1

2

Race from one task to the next *

0

1

2

Rapid heart beat *

0

1

2

Recent injuries, particularly to wrists, shoulders, lower back or knees *

0

1

2

Rectal itching *

0

1

2

Recurrent infections *

0

1

2

Repeated ear trouble *

0

1

2

Restless sleep (toss, turn, wake often) *

0

1

2

Salt cravings *

0

1

2

Self-confidence declined *

0

1

2

Sensitive to heat *

0

1

2

Sensitive to the cold *

0

1

2

Shaking or irritable when hungry *

0

1

2

Short temper *

0

1

2

Signs of poor digestion of fatty foods *

0

1

2

Sinus congestion *

0

1

2

Skin conditions (e.g. Acne, Psoriasis, Rashes, Eczema, etc...) *

0

1

2

Skin oily on nose and forehead *

0

1

2

Sleep with pets on bed *

0

1

2

Sleeps less than 7 hours each night *

0

1

2

Sleepy after eating *

0

1

2

Slow pulse *

0

1

2

Slow reflexes *

0

1

2

Sore throat *

0

1

2

Stomach pain 1 hour after eating or in the night *

0

1

2

Sun damage is more obvious *

0

1

2

Swim in creeks, rivers, lakes *

0

1

2

Symptoms worsen during spring or fall *

0

1

2

Symptoms worsen in parks or grassy areas *

0

1

2

Symptoms worsen when you go indoors or outdoors *

0

1

2

Tabacco smoke really bothers you *

0

1

2

Thinning eyebrows or eyelashes *

0

1

2

Thinning head hair *

0

1

2

Tired upon waking *

0

1

2

Travel in developing countries *

0

1

2

Trouble digesting beans and fiber *

0

1

2

Trouble digesting carbohydrates *

0

1

2

Ulcerative colitis, Crohn's or Coeliacs disease *

0

1

2

Undigested food in stool *

0

1

2

Unexplained crying *

0

1

2

Urinary frequency or urgency *

0

1

2

Use coffee to increase energy *

0

1

2

Use of NSAIDS (e.g. Aspirin, Tylenol, Motrin, etc...) *

0

1

2

Uterine fibroids *

0

1

2

Vaginal burning, itching or discharge *

0

1

2

Varicose veins *

0

1

2

Vertical white streaks on fingernails *

0

1

2

Vertical wrinkles around mouth *

0

1

2

Vitamin B12 deficiency *

0

1

2

Vitamin D deficiency *

0

1

2

Was or is pregnant *

0

1

2

Water retention *

0

1

2

Weak, peeling or cracked fingernails *

0

1

2

Weight gain around abdomen *

0

1

2

Weight gain around your period *

0

1

2

Wheezing *

0

1

2

Wired yet tired *

0

1

2

Wrinkles *

0

1

2

Yellow or pale fingernails *

0

1

2

Yellowish Face *

0

1

2