• Biometrics

  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • What is your BMI?
  • What is your gender?
  • What is your resting heart rate (pulse)?
  • What is your current Systolic (top number) blood pressure?
  • What is your current Diastolic (bottom number) blood pressure?

  • Exercise

  • Do you get regular exercise?
  • What type of exercise do you participate in?
  • How long generally is your exercising/work out?
  • How long are you sore after your exercising/workout?
  • What time of day do you exercise?

  • Diet

  • What best describes your diet?
  • How many servings of caffeine containing drinks do you consume per day?
  • How many times a day do you eat?
  • How many times a day do you eat a starchy food with your meal?
  • How many servings of sweets do you eat daily?
  • How many servings of fruit do you eat per day?
  • Do you make sure fiber is in your daily diet?
  • How many cans of sweetened sodas or other sweetened beverage do you drink daily?
  • How many cans or containers of artificially sweetened beverages do you consume daily?
  • How many alcoholic beverages do you drink weekly?
  • Triad 1: Adrenal

    Triad 1: Adrenal

  • Do you consume caffeine in order to have enough energy to get through your day?
  • Do you get dizzy when standing up from a seated position?
  • Does your energy level drop significantly or do you have an “energy crash” in the mid to late afternoon?
  • Do you feel emotionally flat, less able to feel happiness or joy?
  • Do you stress eat and reach for comfort foods: Sugary foods?
  • Do you stress eat and reach for comfort foods: Salty foods?
  • Do you feel there is too much stress in your life?
  • Do you feel anxious or nervous during the course of your day? If so, what time of day? (Select all that apply)
  • Do you feel overcommitted during the course of your day?
  • Do you get easily agitated and snap at co-workers or family members?
  • Do you meditate or use mind-body techniques such as breathing, yoga, visualization or other techniques to manage stress?
  • Do you have a problem with snacking in the evening or getting up at night to eat?
  • Do you get goosebumps or are you startled easily?
  • Triad 1: Thyroid

    Triad 1: Thyroid

  • Do you feel tired from morning to night?
  • Do you have trouble keeping weight off no matter how much you exercise or diet?
  • Do your hands or feet feel cold most of the time?
  • Do you have trouble getting up in the morning?
  • Do you have dry skin and/or brittle hair or nails?
  • Does your body temperature usually run low (less then 98 degrees F)?
  • Do you have heart palpitations?
  • Do you flush (turn red in the cheeks) easily?
  • Do your hands shake or tremble?
  • Do you eat a lot but can't gain weight?
  • Do you have high energy levels followed by exhaustion or extreme tiredness?
  • Triad 1: Pancreas

    Triad 1: Pancreas

  • Do you get anxious, nervous, shaky or agitated if you go more than 3-4 hours without eating?
  • Are you more than 20 pounds over your ideal body weight?
  • Do you get tired after eating a bigger meal?
  • Do you get nightsweats?
  • Do you get periodic energy crashes during the day that are relieved by food?
  • Have you been told you have pre-diabetes or have insulin resistance?
  • Are you ciurrently taking a GLP-1 peptide (Semaglutide)?
  • Triad 2: Gut

    Triad 2: Gut

  • Do you have constipation?
  • Do you have diarrhea?
  • Do you have constipation and diarrhea alternating?
  • How many bowel movements do you have daily?
  • Have you ever taken antibiotics for an extended period of time and have NOT taken probiotics afterward?
  • Do you feel gassy or bloated?
  • Have you taken cortisone-type ("steroid" drugs) for extended periods of time?
  • Do you get athlete's foot ("jock" itch) or fungus on your skin or nails easily?
  • Do you get symptoms from damp, muggy days, or moldy places?
  • Do you have any known food intolerances or allergies to foods?
  • Do you currently avoid foods that contain gluten?
  • Do you have difficulty thinking clearly at times - like you are “pushing a thought through jello”?
  • Do you belch or burp after eating a meal?
  • Do you feel uncomfortably full after eating?
  • Do you have a history of anemia that doesn't respond well to treatment?
  • Do you get stomach pains before or after eating?
  • Does the stomach pain get worse with excess stress or emotional upset?
  • Have you been told you have acid reflux or a gastrointestinal ulcer?
  • Triad 2: Immune

    Triad 2: Immune

  • Do you have sinus problems?
  • Nasal Congestion?
  • Post-Nasal Drip?
  • Seasonal allergies?
  • Do you sneeze a lot?
  • Do you have itchy or watery eyes or heavy discharge from your eyes?
  • Do you get cold sores or fever blisters often?
  • Do you feel that you get colds/flu or other infections easily?
  • Do you have a history of frequent ear infections?
  • Do you get frequent sore throat or throat infections?
  • Do you have any environmental allergies or chemical sensitivities?
  • Do you get eczema, itch or get skin rashes?
  • Do you breath through your mouth instead of your nose (at night or during the day)?
  • Do your joints or muscles hurt?
  • Do you have a history of herpes?
  • Triad 2: Brain

    Triad 2: Brain

  • Do you currently feel depressed?
  • Do you eat past being full to boost your mood or to feel better?
  • Is your memory worse than it used to be?
  • How many hours of restful sleep do you get on average?
  • Are you a restless sleeper, tossing and turning most of the night?
  • Do you have trouble replaying events over in your head that keep you from falling asleep?
  • How long does it take for you to fall asleep?
  • Do you wake up at night? (Select all that apply)
  • Do you snore to the point others comment?
  • Have you been told by your doctor you have sleep apnea?
  • Have you tested positive for the MTHFR (methylenetetrahydrofolate reductase) gene SNP or have a folate (folic acid) deficiency?
  • Triad 3: Cardiovascular

    Triad 3: Cardiovascular

  • Do your muscles cramp or do you experience restless legs at night?
  • Do you get out of breath easily on exertion such as walking up a flight of stairs?
  • Do you get swelling in your feet or ankles?
  • Do you have chest pain even with light exertion like walking?
  • Do you know if your lipids (cholesterol, triglycerides) are currently elevated?
  • Triad 3: Neuro

    Triad 3: Neuro

  • Have you been told by your doctor that you have high blood pressure AND you are taking prescribed medications?
  • Does your head, arms and/or legs feel heavy and hard to hold up?
  • Do you have ringing or buzzing in your ears?
  • Do your hands or feet feel numb or tingle?
  • Have you been told by your doctor that you have shingles?
  • Triad 3: Pulmonary

    Triad 3: Pulmonary

  • Do you get out of breath easily on exertion?
  • Do you cough?
  • Do you clear your throat?
  • Do you smoke (tobacco or other) OR do you get exposed to “second-hand smoke”?
  • Do you get bronchitis easily?
  • Do you have asthma?
  • Do you live in an industrialized area with large amounts of pollution?
  • Triad 4: Liver

    Triad 4: Liver

  • Do you have trouble digesting greasy and/or fried foods?
  • Do you get discomfort or pain under the right side of your rib cage?
  • Do you have a light colored or yellowish stool?
  • Are the whites of your eyes yellowed?
  • Do you have a sour or metallic taste in your mouth?
  • Do you have bad breath?
  • Do you have excessive body odor?
  • Have you tested positive for heavy metals and have NOT been treated for them?
  • Triad 4: Lymph

    Triad 4: Lymph

  • Do you have eczema or other skin conditions like psoriasis, rosacea or hives?
  • Do you get boils or styes often?
  • Are your lymph glands swollen or sore?
  • Triad 4: Kidney

    Triad 4: Kidney

  • Do you have burning or pain when urinating?
  • Do you have cloudy urine?
  • Do you have trouble holding your urine?
  • Do you have a history of frequent urinary tract infections or cystitis?
  • How many 8 ounce glasses of water do you usually drink daily?
  • How many servings of vegetables do you eat daily?
  • Triad 5: Estrogen (Women)

    Triad 5: Estrogen (Women)

  • Where are you with your menstrual cycle?
  • Which characterizes your cycle?
  • Do you have skin thinning or wrinkling?
  • Have you been diagnosed with uterine fibroids or ovarian cysts?
  • Do you have trouble with weight loss around the thighs no matter what you do?
  • Do you take or use estrogen (synthetic or natural) as hormonal replacement therapy?
  • Do you have osteopenia and/or osteoporosis?
  • Do you have adult acne?
  • Do you have migraine headaches?
  • Do you or did you have a history of erratic periods?
  • Do you feel overwhelmed most of the time?
  • Do you use progesterone (synthetic or natural) as hormonal replacement therapy?
  • Are you unable to achieve an orgasm?
  • Do you have an over-abundance of hair on your body?
  • Is your libido reduced? (Female)
  • Have you lost muscle strength? (Female)
  • Do you take or use testosterone replacement therapy? (Female)
  • Triad 5: Estrogen (Men)

    Triad 5: Estrogen (Men)

  • Do you carry excess weight around your mid-section?
  • Do you have erectile dysfunction?
  • Have you noticed more breast tissue development that's not muscular?
  • Do you notice less urine flow or more?
  • Is your sex drive reduced? (Male)
  • Do you use testosterone replacement therapy? (Male)
  • Do you feel like you have lost strength? (Male)
  • Do you gain weight easily? (Male)
  • Have you lost lean muscle mass? (Male)
  • Triad 5: Drug Induced Nutrient Depletion

    Triad 5: Drug Induced Nutrient Depletion

  • Do you take prescription or non-prescription medications?
  • Do you take acetaminophen (Tylenol)?
  • Are you taking antibiotics presently?
  • Are you taking acid blocking medications (PPIs, H2 blockers)?
  • Are you taking an antihistamine?
  • Are you taking medications for anxiety, to relax or for sleep?
  • Are you prescribed anticonvulsant drugs for seizures or other health condition?
  • Are you taking medications to help control blood sugar levels or diabetes?
  • Are you taking medications for osteoporosis prevention and/or bone health?
  • Are you taking oral or inhaled corticosteroids ("steroids")?
  • Are you taking a medication for your cholesterol called a "statin"?
  • Are you taking any other medications to help lower your cholesterol other than a "statin"?
  • Are you taking "fluid pills" or diuretics?
  • Are you taking a drug for your heart called digitalis or Lanoxin?
  • Are you prescribed a beta-blocker for your heart or blood pressure?
  • Are you taking synthetic estrogen (including Premarin or conjugated estrogens) or progesterone (progestins) hormonal therapies? This does not include natural (bioidentical) hormone therapy.
  • Are you taking potassium prescribed by your doctor?
  • Are you taking an ACE inhibitor or ARB for your blood pressure or heart condition?
  • Are you taking prescribed medications to help improve your memory?
  • Do you take NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil) or naproxen (Aleve)?
  • Do you take oral contraceptives (birth control "pills")?
  • Are you prescribed drugs for pain called opiates?
  • If yes to taking opiates, do these pain medications also contain acetaminophen?
  • Are you prescribed medications for thyroid?

  • Your Sleep

  • Do you ever wake up feeling tired?
  • Has anyone ever mentioned that you snore or seem to stop breathing at night — or have you ever thought you should get a sleep test?
  • Do you ever experience morning headaches, low energy, or grogginess?

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