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Questionnaire

HomeQuestionnaire

QUESTIONNAIRE

Step 1 of 4

25%
Strength indicator
Date of Birth
Please indicate the appropriate number "0 - 4" on all questions below (0 as never to 4 as always).

Category 1

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 or "fuzzy" debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently

Category 2

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
Undigested food found in stools

Category 3

Stomach pain, burning or aching 1-4 hours after eating
Use antacids frequently
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk, carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category 4

Roughage and fiber cause constipation
Indigestion and fullness lasts 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, mucous-like, greasy, or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight

Category 5

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
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 6

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 7

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 8

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 9

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 10

Tired, sluggish
Feel cold - hands, feet, 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
Morning headaches that wear off as the day progresses
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 11

Heart palpations
Inward trembling
Increased pulse even at rest
Nervousness and emotional
Insomnia
Night sweats
Difficulty gaining weight

Category 12

Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms

Category 13

Increased sex drive
Tolerance to sugars reduced
"Splitting" type headaches

Category 14

Decrease in libido
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night

Category 15

Decrease in libido
Decrease in spontaneous morning erections
Urination difficulty or dribbling
Difficulty maintaining 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 than in the past

Category 14

Are you menopausal?
Alternating menstrual cycle lengths
Extended menstrual cycle, greater than 32 days
Shortened menses, less than every 24 days
Pain and cramping during periods
Scanty 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 14

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 breasts
Facial hair growth
Acne
Increased vaginal, pain, dryness, or itching
If you require clarification for any of the questions above, please contact our office prior to submitting your answers.
This field is for validation purposes and should be left unchanged.

58 Melbourne Drive
Richmond Hill, ON L4S 2V2
Canada

905 780 9908
info@catanzarogroup.com

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