Name *

First Name

Last Name

Brain Chemistry

Choose all that apply.

Sensitivity to emotional (or physical) pain; cry easily - 4

Eat as a reward or for pleasure, comfort, or numbness - 4

Worry, anxiety, phobia, or panic - 4

Difficulty getting to sleep or staying asleep - 4

Difficulty with focus, attention deficits - 3

Low energy, drive, and arousal - 2

Obsessive thinking or behavior - 4

Inability to relax after tension, stress - 4

Depression, negativity - 3

Low self-esteem, lack of confidence - 4

More mood and eating problems in winter or at the end of the day - 4

Irritability, anger - 3

Use alcohol or drugs to improve mood - 4

Low Caloric Intake

Choose all that apply.

Increased cravings for and focus on food; overeating - 4

Regain weight after dieting, more than was lost - 4

Increased moodiness, irritability, anxiety, or depression - 3

Less energy and endurance - 3

Usually eat less than 2,100 calories a day - 3

Skip meals, especially breakfast - 3

Eat mostly low-fat carbohydrates (bagels, pasta, frozen yogurt, and others) - 3

Constantly think about weight - 2

Use aspartame (Nutrasweet) daily - 2

Take Prozac or similar serotonin-boosting drugs - 2

Have become vegetarian - 2

Have decreased self-esteem - 3

Have become bulimic, anorectic, or an overexercizer - 4

Blood Sugar Instability

Choose all that apply.

Crave a lift from sweets or alcohol, but later experience a drop in energy and mood after ingesting them - 4

Dizzy, weak, or headachy, especially if meals are delayed - 4

Family history of diabetes, hypoglycemia, or alcoholism - 4

Nervous, jittery, irritable on and off throughout the day; calmer after meals - 4

Crying spells, mood swings - 4

Mental confusion, decreased memory - 4

Heart palpitations, rapid pulse - 4

Frequent thirst, night sweats (not menopausal) - 4

Stress and Adrenal Exhaustion

Choose all that apply.

Frequently overstressed for more than 3 weeks at a time - 4

Crave salty foods - 3

Frequently feel fatigued, overwhelmed - 4

Dark circles under eyes - 4

Sensitive to sounds, odors; startle easily - 4

Edgy, irritable under stress - 3

Have excessive weight gain in your trunk only - 3

Thyroid Function

Choose all that apply.

Low energy - 4

Easily chilled (especially hands and feet) - 4

Other family members have thyroid problems - 4

Can gain weight without overeating; hard to lose excess weight - 4

Have to force yourself to do even moderate exercise - 3

Find it hard to get going in the morning - 4

High cholesterol - 3

Low blood pressure - 3

Weight gain began near the start of menses, a pregnancy, or menopause - 4

Chronic headaches - 3

Use food, caffeine, tobacco, and/or other stimulants to get going - 3

Food Addiction/Intolerance

Choose all that apply.

Crave milk, ice cream, yogurt, cheese, or doughy foods (pasta, bread, cookies, among others) and eat them frequently - 3

Experience bloating after meals - 3

Gas, frequent belching - 4

Digestive discomfort of any kind - 3

Chronic constipation and/or diarrhea - 3

Respiratory problems, such as asthma, postnasal drip, congestion - 4

Low energy or drowsiness, especially after meals - 3

Allergic to milk products or other common foods - 4

Under eat or often prefer beverages to solid food - 3

Avoid food or throw up food because bloating after eating makes you feel fat or tired - 3

Can’t gain weight - 4

Hyperactivity or manic-depression - 3

Severe headaches, migraines - 3

Food allergies in family - 4

Hormones (Female Only)

Choose all that apply.

Premenstrual mood swings - 4

Premenstrual or menopausal food cravings - 4

Irregular periods - 4

Experienced a miscarriage, an abortion, or infertility - 3

Use(d) birth control pills or other hormone medication - 4

Uncomfortable periods—cramps, lengthy or heavy bleeding, or sore breasts - 3

Peri- or postmenopausal discomfort (e.g., hot flashes, sweats, insomnia, or mental dullness) - 4

Excessive hair growth or loss, acne - 3

Yeast/Gut Issues

Choose all that apply.

Often bloated, abdominal distention - 4

Foggy-headed - 3

Depressed - 2

Yeast or Sinus infections - 4

Used antibiotics extensively (at any time in life) - 4

Used cortisone or birth control pills for more than one year - 4

Have chronic fungus on nails or feet - 4

Recurring sinus or ear infections as an adult or child - 3

Achy muscles and joints - 3

Chronically fatigued - 3

Rashes - 4

Stool unusual in color, shape, or consistency - 3

Fatty Acid Deficiency

Choose all that apply.

Crave chips, cheese, and other rich foods more than, or in addition to, sweets and starches - 4

Have ancestry that includes Irish, Scottish, Welsh, Scandinavian, or coastal Native American - 4

Alcoholism or depression in the family history - 3

Feel heavy, uncomfortable, and “clogged up” after eating fatty foods - 4

History of hepatitis or other liver or gallbladder problems - 4

Light-colored stool - 4

Hard or foul-smelling stool - 4

Pain on right side under your rib cage - 1

Have lost your gall bladder or had gallstones - 2