Biometrics
First Name
Last Name
Email
What is your weight in pounds?
Height - Feet
Height - Inches
What is your gender?
Male
Female
What is your resting heart rate (pulse)?
Don't know
<40
40-69
70-76
77-80
>80
What is your current Systolic (top number) blood pressure?
Don't know
<80
80-109
110-120
121-145
>145
What is your current Diastolic (bottom number) blood pressure?
Don't know
<40
40-59
60-85
86-100
>100
What is your salivary pH?
5-6
6.1-6.9
7-7.2
7.3-7.8
> 7.8
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Exercise
Do you get regular exercise?
Never
Rarely
Sometimes
Frequently/Often
Always
What type of exercise do you participate in?
Walking
Weight Lifting
Yoga/Pilates
Biking/Aerobics
How long generally is your exercising/work out?
1hr or <
> 1 hr
How long are you sore after your exercising/workout?
< 24hr
24.1-48 hr
48.1-72 hr
>72 hr
What time of day do you exercise?
Morning
Afternoon
Evening
Time Varies
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Diet
What best describes your diet?
None - eat anything you want
Paleo
Low Carb
Mediterranean
Vegetarian
Calorie Controlled (i.e. Weight Watchers®, Slim Fast®, etc…)
Ketogenic
How many servings of caffeine containing drinks do you consume per day?
0
1 to 2
3 to 5
>5
How many times a day do you eat?
0-2
3 to 4
5 or more
How many times a day do you eat a starchy food with your meal?
0
1 to 2
3 or more
How many servings of sweets do you eat daily?
0
1 to 2
3 or greater
How many servings of fruit do you eat per day?
0
1
2
3
>3
Do you make sure fiber is in your daily diet?
Never
Rarely
Sometimes
Frequently / Often
Always
How many cans of sweetened sodas or other sweetened beverage do you drink daily?
0
1 to 2
2 or more
How many cans or containers of artificially sweetened beverages do you consume daily?
0
1 to 2
2 or more
How many alcoholic beverages do you drink weekly?
0-2
3 to 7
8 to 14
More than 2 drink daily
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Triad 1: Adrenal
Do you consume caffeine in order to have enough energy to get through your day?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get dizzy when standing up from a seated position?
Never
Rarely
Sometimes
Frequently/Often
Always
Does your energy level drop significantly or do you have an “energy crash” in the mid to late afternoon?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel emotionally flat, less able to feel happiness or joy?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you stress eat and reach for comfort foods: Sugary foods?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you stress eat and reach for comfort foods: Salty foods?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel there is too much stress in your life?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel anxious or nervous during the course of your day? If so, what time of day? (Select all that apply)
Morning
Noon
Night
Do you feel overcommitted during the course of your day?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get easily agitated and snap at co-workers or family members?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you meditate or use mind-body techniques to manage stress?
NEVER
Rarely
Sometimes
Frequently/Often
Always
Do you have a problem with snacking in the evening or getting up at night to eat?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get goosebumps or are you startled easily?
Never
Rarely
Sometimes
Frequently/Often
Always
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Triad 1: Thyroid
Do you feel tired from morning to night?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have trouble keeping weight off no matter how much you exercise or diet?
Yes
No
Do your hands or feet feel cold most of the time?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have trouble getting up in the morning?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have dry skin and/or brittle hair or nails?
Never
Rarely
Sometimes
Frequently/Often
Always
Does your body temperature usually run low (less then 98 degrees F)?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have heart palpitations?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you flush (turn red in the cheeks) easily?
Never
Rarely
Sometimes
Frequently/Often
Always
Do your hands shake or tremble?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you eat a lot but can't gain weight?
Yes
No
Do you have high energy levels followed by exhaustion or extreme tiredness?
Never
Rarely
Sometimes
Frequently/Often
Always
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Triad 1: Pancreas
Do you get anxious, nervous, shaky or agitated if you go more than 3-4 hours without eating?
Never
Rarely
Sometimes
Frequently/Often
Always
Are you more than 20 pounds over your ideal body weight?
Yes
No
Do you get tired after eating a bigger meal?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get nightsweats?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you been told you have pre-diabetes or have insulin resistance?
Yes
No
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Triad 2: Gut
Do you get nightsweats?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have constipation?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have diarrhea?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have constipation and diarrhea alternating?
Never
Rarely
Sometimes
Frequently/Often
Always
How many bowel movements do you have daily?
0
1 to 3
>3
Have you ever taken antibiotics for an extended period of time and have NOT taken probiotics afterward?
Yes
No
Do you feel gassy or bloated?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you taken cortisone-type ("steroid" drugs) for extended periods of time?
Yes
No
Do you get athlete's foot ("jock" itch) or fungus on your skin or nails easily?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get symptoms from damp, muggy days, or moldy places?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have any known food intolerances or allergies to foods?
Yes
No
Do you currently avoid foods that contain gluten?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have difficulty thinking clearly at times - like you are “pushing a thought through jello”?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you belch or burp after eating a meal?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel uncomfortably full after eating?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a history of anemia that doesn't respond well to treatment?
Yes
No
Do you get stomach pains before or after eating?
Yes
No
Does the stomach pain get worse with excess stress or emotional upset?
Yes
No
Have you been told you have acid reflux or a gastrointestinal ulcer?
Yes
No
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Triad 2: Immune
Do you have sinus problems?
Yes
No
Nasal Congestion?
Never
Rarely
Sometimes
Frequently/Often
Always
Post-Nasal Drip?
Never
Rarely
Sometimes
Frequently/Often
Always
Seasonal allergies?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you sneeze a lot?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have itchy or watery eyes or heavy discharge from your eyes?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get cold sores or fever blisters often?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel that you get colds/flu or other infections easily?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a history of frequent ear infections?
Yes
No
Do you get frequent sore throat or throat infections?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have any environmental allergies or chemical sensitivities?
Yes
No
Do you get eczema, itch or get skin rashes?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you breath through your mouth instead of your nose (at night or during the day)?
Never
Rarely
Sometimes
Frequently/Often
Always
Do your joints or muscles hurt?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a history of herpes?
Yes
No
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Triad 2: Brain
Do you currently feel depressed?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you eat past being full to boost your mood or to feel better?
Never
Rarely
Sometimes
Frequently/Often
Always
Is your memory worse than it used to be?
Never
Rarely
Sometimes
Frequently/Often
Always
How many hours of restful sleep do you get on average?
<3
3 to 4
5 to 6
7 to 9
>9
Are you a restless sleeper, tossing and turning most of the night?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have trouble replaying events over in your head that keep you from falling asleep?
Never
Rarely
Sometimes
Frequently/Often
Always
How long does it take for you to fall asleep?
<15 minutes
15-30 minutes
>30 minutes
Do you wake up at night? (Select all that apply)
To urinate
Craving food
Just wake up
It is easy to fall back asleep
Do you snore to the point others comment?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you been told by your doctor you have sleep apnea?
Yes
No
Have you tested positive for the MTHFR (methylenetetrahydrofolate reductase) gene SNP or have a folate (folic acid) deficiency?
Yes
No
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Triad 3: Cardiovascular
Do your muscles cramp or do you experience restless legs at night?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get out of breath easily on exertion such as walking up a flight of stairs?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get swelling in your feet or ankles?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have chest pain even with light exertion like walking?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you know if your lipids (cholesterol, triglycerides) are currently elevated?
Yes
No
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Triad 3: Neuro
Have you been told by your doctor that you have high blood pressure AND you are taking prescribed medications?
Yes
No
Does your head, arms and/or legs feel heavy and hard to hold up?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have ringing or buzzing in your ears?
Never
Rarely
Sometimes
Frequently/Often
Always
Do your hands or feet feel numb or tingle?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you been told by your doctor that you have shingles?
Yes
No
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Triad 3: Pulmonary
Do you get out of breath easily on exertion?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you cough?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you clear your throat?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you smoke (tobacco or other) OR do you get exposed to “second-hand smoke”?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get bronchitis easily?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have asthma?
Yes
No
Do you live in an industrialized area with large amounts of pollution?
No
I have in the Past
I do now
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Triad 4: Liver
Do you have trouble digesting greasy and/or fried foods?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get discomfort or pain under the right side of your rib cage?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a light colored or yellowish stool?
Never
Rarely
Sometimes
Frequently/Often
Always
Are the whites of your eyes yellowed?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a sour or metallic taste in your mouth?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have bad breath?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have excessive body odor?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you tested positive for heavy metals and have NOT been treated for them?
Yes
No
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Triad 4: Lymph
Do you have eczema or other skin conditions like psoriasis, rosacea or hives?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you get boils or styes often?
Yes
No
Are your lymph glands swollen or sore?
Never
Rarely
Sometimes
Frequently/Often
Always
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Triad 4: Kidney
Do you have burning or pain when urinating?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have cloudy urine?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have trouble holding your urine?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you have a history of frequent urinary tract infections or cystitis?
Yes
No
How many 8 ounce glasses of water do you usually drink daily?
0-2
3 to 4
5 to 8
>8
How many servings of vegetables do you eat daily?
0
1 to 2
3 to 5
6 to 7
>7
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Triad 5: Estrogen (Women)
Where are you with your menstrual cycle?
Ovulating
Peri-menopause
Post-menopause or menopause
Not Applicable / Male
Which characterizes your cycle?
Regular
Irregular cycle or Heavy Periods
Generally has symptoms (breast tenderness, mood changes, fluid retention or hot flashes)
Not Applicable
Do you have skin thinning or wrinkling?
Yes
No
Have you been diagnosed with uterine fibroids or ovarian cysts?
Yes
No
Do you have trouble with weight loss around the thighs no matter what you do?
Yes
No
Do you take or use bioidentical estrogen replacement therapy?
Yes
No
Do you have osteopenia and/or osteoporosis?
Yes
No
Do you have adult acne?
Yes
No
Do you have migraine headaches?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you or did you have a history of erratic periods?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you feel overwhelmed most of the time?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you use bioidentical progesterone replacement therapy?
Yes
No
Are you unable to achieve an orgasm?
Yes
No
Do you have an over-abundance of hair on your body?
Yes
No
Is your libido reduced? (Female)
Never
Rarely
Sometimes
Frequently/Often
Always
Have you lost muscle strength? (Female)
Yes
No
Do you take or use testosterone replacement therapy? (Female)
Yes
No
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Triad 5: Estrogen (Men)
Do you carry excess weight around your mid-section?
Yes
No
Do you have erectile dysfunction?
Never
Rarely
Sometimes
Frequently/Often
Always
Have you noticed more breast tissue development that's not muscular?
Yes
No
Do you notice less urine flow or more?
Never
Rarely
Sometimes
Frequently/Often
Always
Is your sex drive reduced? (Male)
Never
Rarely
Sometimes
Frequently/Often
Always
Do you use testosterone replacement therapy? (Male)
Yes
No
Do you feel like you have lost strength? (Male)
Yes
No
Do you gain weight easily? (Male)
Yes
No
Have you lost lean muscle mass? (Male)
Yes
No
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Triad 5: Drug Induced Nutrient Depletion
Do you take acetaminophen (Tylenol)?
Never
Rarely
Sometimes
Frequently/Often
Always
Are you taking antibiotics presently?
Yes
No
Are you taking acid blocking medications (PPIs, H2 blockers)?
Yes
No
Are you taking an antihistamine?
Yes
No
Are you taking medications for anxiety, to relax or for sleep?
Yes
No
Are you prescribed anticonvulsant drugs for seizures or other health condition?
Yes
No
Are you taking medications to help control blood sugar levels or diabetes?
Yes
No
Are you taking medications for osteoporosis prevention and/or bone health?
Yes
No
Are you taking oral or inhaled corticosteroids ("steroids")?
Yes
No
Are you taking a medication for your cholesterol called a "statin"?
Yes
No
Are you taking any other medications to help lower your cholesterol other than a "statin"?
Yes
No
Are you taking "fluid pills" or diuretics?
Yes
No
Are you taking a drug for your heart called digitalis or Lanoxin?
Yes
No
Are you prescribed a beta-blocker for your heart or blood pressure?
Yes
No
Are you taking hormonal replacement therapy, including synthetic estrogens (including Premarin or conjugated estrogen) or progestins?
Yes
No
Are you taking potassium prescribed by your doctor?
Yes
No
Are you taking an ACE inhibitor or ARB for your blood pressure or heart condition?
Yes
No
Are you taking prescribed medications to help improve your memory?
Yes
No
Do you take NSAIDs (non-steroidal anti-inflammatory drugs) like ibuprofen (Advil) or naproxen (Aleve)?
Never
Rarely
Sometimes
Frequently/Often
Always
Do you take oral contraceptives (birth control "pills")?
Yes
No
Are you prescribed drugs for pain called opiates?
Yes
No
If yes to taking opiates, do these pain medications also contain acetaminophen?
Yes
No
Are you prescribed medications for thyroid?
Yes
No
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