leychiropractic.com - CellCore Clinical Assessment Form

Assessment Forms
Name
Date

MonthDayYear
Date
Instructions
Rate each of the symptoms to the best of your ability based on the last 90 days. For Yes/No answers, select the number next to your answer, if there is a number. Compare your results with the rating system. A score in the yellow or red range suggests this area is more likely a problem for you.

Mitochondrial Dysfunction

Rows	Never	Occasionally	Often	Regularly
Dizziness upon standing up quickly
Unable to tolerate much exercise
Poor exercise or muscle stamina
Brain fog
Difficulty focusing
Vision or hearing problems
General or chronic fatigue
Afternoon headaches
Migraines or seizures
Mood problems: anxiety, depression, or bipolar
Poor brain processing (cognition)
Blood sugar issues
Breathing problems
Intolerant to heat
Chronic inflammation
Cannot fall asleep
Cannot stay asleep
Slow mover in the morning (hard to get going)
Wake up tired, even after 6 or more hours of sleep
Eyes sensitive to bright or direct light
Weight gain when under stress

Mitochondrial Dysfunction

Rows	Yes	No
History of infections (EBV, Lyme, etc.)?
Low muscle tone?
Overweight?
Low body temperature
Low thyroid lab numbers?
Little or no skin sweating?
Suppressed immune system?
Catch colds or get sick easily?
Loss of libido

Green	Yellow	Red
0-16	17-45	46-107

Drainage Dysfunction Susceptibility

Rows	Never	Occasionally	Often	Regularly
Constipation (pooping one or fewer times daily)
Feeling that bowels do not empty completely
General or chronic fatigue
Mood problems: anxiety, depression, or bipolar
Poor brain processing (cognition)
Chronic inflammation
Wake up between 1 a.m. to 4 a.m.
Edema, swelling or retain extra fluids
Skin problems, rashes, itches, hives, eczema, or acne
Yellowish skin, face
Suppressed immune system
Can't clear infections, despite following pathogen protocols
Sore or swollen breast tissue
Heart palpitations or irregular heartbeat
Light, sound, or EMF sensitivities
Morning stiffness
Brain fog
Swollen glands
Cellulite or flabby skin
Varicose or spider veins
Kidney problems
Breathing or lung issues
Skin doesn't sweat
Puffy Eyes

Green	Yellow	Red
0-14	15-35	36-72

Minerals & Electrolytes

Rows	Never	Occasionally	Often	Regularly
Edema (swelling) in ankles or wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Unable to hold breath for long periods
Shallow, rapid breathing
Bone loss (reduced density on bone scan)
Crave chocolate
Feet have a strong odor
History of anemia
Whites of eyes (sclera) are blue-tinted
Hoarse voice
White spots on fingernails

Minerals & Electrolytes

Rows	Yes	No
History of carpal tunnel syndrome
History of lower right abdominal pains or ileocecal valve problems
History of stress fracture

Green	Yellow	Red
0-19	20-35	36-59

Blood Sugar

Rows	Never	Occasionally	Often	Regularly
Crave sweets during the day
Irritable if meals are missed
Eating relieves fatigue
Agitated, easily upset, nervous
Fatigue after meals
Must have sweets after meals
Forgetful; poor memory
Feel better or calmer after eating
Prone to infections and colds

Blood Sugar

Rows	Yes	No
History of diabetes in your family
Sugar (glucose) detected in urine test?
Hair loss at ankles/frictional alopecia?

Green	Yellow	Red
0-10	11-24	25-45

Rows	Never	Occasionally	Often	Regularly
Belching or burping
Gas quickly following a meal
Bad breath
Feel full while eating and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Stomach pain, burning, or aching 1 to 4 hours after eating
Temporary relief by using antacids, food, milk, or carbonated beverages
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine
Indigestion
Abdominal bloating
Constipation
Diminished appetite

Rows	Never	Occasionally	Often	Regularly
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or buildup of debris on tongue
Use laxatives
History of bladder and/or kidney infection
Yeast infection (including vaginal)
Fingernail and/or toenail fungus

Rows	Never	Occasionally	Often	Regularly
Increased gut motility, diarrhea
Alternating constipation and diarrhea
Mucus in stool
Poorly formed or loose stools
Four or more large stools daily
Stools have foul odor
Suspect nutrient malabsorption
Diagnosed with celiac disease, irritable bowel syndrome (IBS), or diverticulosis/diverticulitis
Stomach cramps
Flatulence (gas)
Fiber-rich diet doesn’t help constipation

Rows	Never	Occasionally	Often	Regularly
Adverse reactions to foods
Unpredictable food reactions
Aches, pains, and swelling throughout your body
Unpredictable abdominal swelling
Food allergies
Frequent bloating and distention after eating

Rows	Never	Occasionally	Often	Regularly
Tired or sluggish
Feel cold (hands, feet, or your whole body)
Require an excessive amount of sleep to function properly
Gain weight easily
Difficult, infrequent bowel movements
Depression or lack of motivation
Thinning of outer third of eyebrows
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Dry skin and/or scalp
Slow brain processing
Lack of or diminished sex drive
Heavy or profuse menstrual bleeding (women only)

Assessment Forms

Rows	Yes	No
Ever diagnosed with Lyme disease?
Ever bitten by a tick?
Ever had a bullseye rash on any part of your body?
Mother ever diagnosed with Lyme disease?
Spouse/partner/significant other diagnosed with Lyme disease?
Ever diagnosed with chronic fatigue syndrome, fibromyalgia, lupus, rheumatoid arthritis (RA), multiple sclerosis (MS), or an autoimmune condition?
Ever diagnosed with Parkinson’s disease, Alzheimer’s disease, or Tourette’s syndrome?
Frequently go camping, hunting, or engage in outdoor activities?
History of a heart murmur or valve prolapse?

Rows	Yes	No
Live on or near a golf course?
Live near a freeway or high-tension wires?
Wear conventional sunscreen?
Wear perfume or cologne?
Use air fresheners in your house, car, or workplace?
Were you the first-born child?

Rows	Yes	No
History of or currently have cancer?
Suppressed immune system?
Osteoporosis or osteopenia diagnosis?
Can't clear infections, despite following pathogen protocols?

Rows	Yes	No
Do you have amalgam (silver) fillings in your teeth?
Have you ever had an amalgam removed?
If you had amalgams removed, was it done by a biological dentist using a safe protocol?
Were there amalgam fillings in your mother's mouth while she was pregnant with you?
Do you have compact fluorescent (CFL) bulbs in your home?
Have you broken any CFL bulbs? (reference)

Rows	Yes	No
See mold growing at home, work, or school?
Ever experienced water damage at home, work, or school?
Basement ever wet?
Symptoms decrease when spend time in a different location for at least a few days?
Plumbing in your kitchen or bathroom leaks or has leaked in the past?
Wet spots anywhere in your home (whether currently or past)?
Often see condensation (fog) on the inside of windows and/or cold surfaces in your home?
Car has a mildewy smell?
Any skin conditions?
Anyone in your home have asthma-like symptoms?

Green	Yellow	Red
0-11	12-26	27-36

Green	Yellow	Red
0-9	10-24	25-36

Green	Yellow	Red
0-8	7-15	16-24

Green	Yellow	Red
0-11	12-22	23-40