QUESTIONNAIRE Step 1 of 4 25% Name Email PhonePassword Strength indicator Weight UnitkglbHeight UnitcminftAge Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderMaleFemaleMenstruatingMenstruatingMenopausalPlease list your 5 major health concerns in order of importance:Please list your 5 major health and fitness goals in order of importance:Do you wish to gain, lose, or maintain your current body weight? Please indicate the appropriate number "0 - 4" on all questions below (0 as never to 4 as always).Category 1Feeling that bowels do not empty completely 0 1 2 3 4 Lower abdominal pain relief by passing stool or gas 0 1 2 3 4 Alternating constipation and diarrhea 0 1 2 3 4 Diarrhea 0 1 2 3 4 Constipation 0 1 2 3 4 Hard dry or small stool 0 1 2 3 4 Coated tongue or "fuzzy" debris on tongue 0 1 2 3 4 Pass large amount of foul-smelling gas 0 1 2 3 4 More than 3 bowel movements daily 0 1 2 3 4 Use laxatives frequently 0 1 2 3 4 Category 2Excessive belching, burping, or bloating 0 1 2 3 4 Gas immediately following a meal 0 1 2 3 4 Offensive breath 0 1 2 3 4 Difficult bowel movements 0 1 2 3 4 Sense of fullness during and after meals 0 1 2 3 4 Difficulty digesting fruits and vegetables 0 1 2 3 4 Undigested food found in stools 0 1 2 3 4 Category 3Stomach pain, burning or aching 1-4 hours after eating 0 1 2 3 4 Use antacids frequently 0 1 2 3 4 Feeling hungry an hour or two after eating 0 1 2 3 4 Heartburn when lying down or bending forward 0 1 2 3 4 Temporary relief from antacids, food, milk, carbonated beverages 0 1 2 3 4 Digestive problems subside with rest and relaxation 0 1 2 3 4 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine 0 1 2 3 4 Category 4Roughage and fiber cause constipation 0 1 2 3 4 Indigestion and fullness lasts 2-4 hours after eating 0 1 2 3 4 Pain, tenderness, soreness on left side under rib cage 0 1 2 3 4 Excessive passage of gas 0 1 2 3 4 Nausea and/or vomiting 0 1 2 3 4 Stool: undigested, foul smelling, mucous-like, greasy, or poorly formed 0 1 2 3 4 Frequent urination 0 1 2 3 4 Increased thirst and appetite 0 1 2 3 4 Difficulty losing weight 0 1 2 3 4 Category 5Greasy or high-fat foods cause distress 0 1 2 3 4 Lower bowel gas and or bloating several hours after eating 0 1 2 3 4 Bitter metallic taste in mouth especially in the morning 0 1 2 3 4 Unexplained itchy skin 0 1 2 3 4 Yellowish cast to eyes 0 1 2 3 4 Stool color alternates from clay-colored to normal brown 0 1 2 3 4 Reddened skin, especially palms 0 1 2 3 4 Dry or flaky skin and/or hair 0 1 2 3 4 History of gallbladder attacks or stones 0 1 2 3 4 Have you had your gallbladder removed? 0 1 2 3 4 Category 6Crave sweets during the day 0 1 2 3 4 Irritable if meals are missed 0 1 2 3 4 Depend on coffee to keep yourself going or started 0 1 2 3 4 Get lightheaded if meals are missed 0 1 2 3 4 Eating relieves fatigue 0 1 2 3 4 Feel shaky, jittery, tremors 0 1 2 3 4 Agitated, easily upset, nervous 0 1 2 3 4 Poor memory, forgetful 0 1 2 3 4 Blurred vision 0 1 2 3 4 Category 7Fatigue after meals 0 1 2 3 4 Crave sweets during the day 0 1 2 3 4 Eating sweets does not relieve cravings for sugar 0 1 2 3 4 Must have sweets after meals 0 1 2 3 4 Waist girth is equal or larger than hip girth 0 1 2 3 4 Frequent urination 0 1 2 3 4 Increased thirst and appetite 0 1 2 3 4 Difficulty losing weight 0 1 2 3 4 Category 8Cannot stay asleep 0 1 2 3 4 Crave salt 0 1 2 3 4 Slow starter in the morning 0 1 2 3 4 Afternoon fatigue 0 1 2 3 4 Dizziness when standing up quickly 0 1 2 3 4 Afternoon headaches 0 1 2 3 4 Headaches with exertion or stress 0 1 2 3 4 Weak nails 0 1 2 3 4 Category 9Cannot fall asleep 0 1 2 3 4 Perspire easily 0 1 2 3 4 Under high amounts of stress 0 1 2 3 4 Weight gain when under stress 0 1 2 3 4 Wake up tired even after 6 or more hours of sleep 0 1 2 3 4 Excessive perspiration or perspiration with little or no activity 0 1 2 3 4 Category 10Tired, sluggish 0 1 2 3 4 Feel cold - hands, feet, all over 0 1 2 3 4 Require excessive amounts of sleep to function properly 0 1 2 3 4 Increase in weight gain even with low-calorie diet 0 1 2 3 4 Gain weight easily 0 1 2 3 4 Difficult, infrequent bowel movements 0 1 2 3 4 Morning headaches that wear off as the day progresses 0 1 2 3 4 Outer third of eyebrow thins 0 1 2 3 4 Thinning of hair on scalp, face or genitals, or excessive falling hair 0 1 2 3 4 Dryness of skin and/or scalp 0 1 2 3 4 Mental sluggishness 0 1 2 3 4 Category 11Heart palpations 0 1 2 3 4 Inward trembling 0 1 2 3 4 Increased pulse even at rest 0 1 2 3 4 Nervousness and emotional 0 1 2 3 4 Insomnia 0 1 2 3 4 Night sweats 0 1 2 3 4 Difficulty gaining weight 0 1 2 3 4 Category 12Diminished sex drive 0 1 2 3 4 Menstrual disorders or lack of menstruation 0 1 2 3 4 Increased ability to eat sugars without symptoms 0 1 2 3 4 Category 13Increased sex drive 0 1 2 3 4 Tolerance to sugars reduced 0 1 2 3 4 "Splitting" type headaches 0 1 2 3 4 Category 14Decrease in libido 0 1 2 3 4 Frequent urination 0 1 2 3 4 Pain inside of legs or heels 0 1 2 3 4 Feeling of incomplete bowel evacuation 0 1 2 3 4 Leg nervousness at night 0 1 2 3 4 Category 15Decrease in libido 0 1 2 3 4 Decrease in spontaneous morning erections 0 1 2 3 4 Urination difficulty or dribbling 0 1 2 3 4 Difficulty maintaining morning erections 0 1 2 3 4 Spells of mental fatigue 0 1 2 3 4 Inability to concentrate 0 1 2 3 4 Episodes of depression 0 1 2 3 4 Muscle soreness 0 1 2 3 4 Decrease in physical stamina 0 1 2 3 4 Unexplained weight gain 0 1 2 3 4 Increase in fat distribution around chest and hips 0 1 2 3 4 Sweating attacks 0 1 2 3 4 More emotional than in the past 0 1 2 3 4 Category 14Are you menopausal? 0 1 2 3 4 Alternating menstrual cycle lengths 0 1 2 3 4 Extended menstrual cycle, greater than 32 days 0 1 2 3 4 Shortened menses, less than every 24 days 0 1 2 3 4 Pain and cramping during periods 0 1 2 3 4 Scanty blood flow 0 1 2 3 4 Breast pain and swelling during menses 0 1 2 3 4 Pelvic pain during menses 0 1 2 3 4 Irritable and depressed during menses 0 1 2 3 4 Acne breakouts 0 1 2 3 4 Facial hair growth 0 1 2 3 4 Hair loss/thinning 0 1 2 3 4 Category 14How many years have you been menopausal? 0 1 2 3 4 Do you ever have uterine bleeding since menopause? 0 1 2 3 4 Hot flashes 0 1 2 3 4 Mental fogginess 0 1 2 3 4 Disinterest in sex 0 1 2 3 4 Mood swings 0 1 2 3 4 Depression 0 1 2 3 4 Painful intercourse 0 1 2 3 4 Shrinking breasts 0 1 2 3 4 Facial hair growth 0 1 2 3 4 Acne 0 1 2 3 4 Increased vaginal, pain, dryness, or itching 0 1 2 3 4 How many alcohol 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 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? Rate your stress levels on a scale of 1-10 during the average week: Please list any medical condition(s) that you have been diagnosed with in the past: Please list all medications you currently take and for what conditions: Please list any natural supplements you currently take and for what conditions: Has a doctor recommended that you take specific vitamins, minerals, or other supplements for your health? If yes, please list which ones: Please list any allergies you have: Are there any ingredients that may be found in a natural supplement that you are allergic to? If yes, please list which ones: Do you have any concerns from taking natural supplements? If yes, please list your concerns: Please list any other information that you believe is relevant that may affect your health or safety when taking a natural supplement: If you require clarification for any of the questions above, please contact our office prior to submitting your answers.NameThis field is for validation purposes and should be left unchanged.
