Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Excessive belching, burping or bloating

Flatulence

Sense of fullness during and after meals

Alternating diarrhea and constipation

Constipation

Diarrhea or loose, unformed stool

Abdominal pain

Burning sensation in stomach 1-4 hours after eating

Use antacids



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Crave sweets during the day

Irritable if meals are missed

Need coffee to get started or keep yourself going

Eating relieves fatigue

Get lightheaded if meals are missed

Agitated, easily upset, nervous

Fatigue after meals

Eating sweets doesn't relieve cravings for sugar

Must have sweet after meals

Frequent urination

Increased thirst and appetite



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Difficulty losing weight

Weight gain even with low-calorie diet

Waist girth is equal or larger to hip girth

Accumulation of belly fat



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Tired, sluggish

Not enough energy to get through the day

Energy fluctuates throughout the day

Easily fatigued

Diminished sex drive



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Inability to concentrate or focus

Difficulty remembering things

Decreased attention span

Depression or lack of motivation

Anxiety

Insomnia or restless sleep

Heart palpitations



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Muscle soreness or pain

Joint soreness or pain

Decreased joint mobility

Swelling of joints

Whole body pain



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Itchy skin

Skin rashes (eczema, psoraisis, hives, etc.)

Dry skin

Acne breakouts



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   
Tendency to feel cold: hands, feet, all over

Thinning of outer third of eyebrow

Hair loss or thinning of hair

Dryness of skin or scalp

Brain fog / difficulty concentrating

Low energy, even with adequate sleep

Difficulty losing weight

Depression and lack of motivation



Question Section

First: Figure Out Where You Are Now

 

Use the numbers below to indicate how frequently you experience the symptoms on the left.
(0 = rarely or never, 3 = frequently)

   

Male:

Decrease in libido

Decrease in morning erections

Brain fog (difficulty concentrating)

Poor exercise tolerance and/or recovery

Increase in fat in abdomen, breasts and chin

Mood swings

Menstruating female:

Short, extended, or irregular menstrual cycle length

Heavy or scanty menstrual flow

Pain, cramping or discomfort during periods

Premenstrual syndrome

Acne and skin disorders

Facial hair growth and/or hair loss/thinning

Menopausal female:

Hot flashes

Low libido

Mood swings

Vaginal dryness, itching

Acne and skin disorders

Brain fog (difficulty concentrating)

Fertility, Pregnancy and Breastfeeding:

Are you currently pregnant or breastfeeding?

Are you currently trying to conceive, or planning to conceive within the next two years?