• Comprehensive Health Evaluation

  • Serotonin

  • 1. Feel depressed, unhappy, or sad
  • 2. You can’t stay asleep and/or lack of deep restorative sleep
  • 3. Compulsive behavior, unprovoked anger and/or unexplained crying

  • Dopamine

  • 4. Feel anxious or have social phobia
  • 5. Have addictive personality; Past/present troubles with alcohol, food, pharmaceutical and recreational drugs.
  • 6. Have troubles staying focused on one particular task
  • 7. Life seems less fun, colorful or flavorful, lack pleasure

  • Acetylcholine

  • 8. Lapses in memory
  • 9. Difficulty comprehending verbal instructions

  • Gaba

  • 10. Feel tense and/or have troubles turning your mind off when you want to relax
  • 11. Feel irritable, crabby or short tempered
  • 12. You often use alcohol or other sedatives to calm down

  • Stress

  • 13. Feelings of hopelessness
  • 14. Feelings of being overwhelmed
  • 15. Events from the past cause you pain, resentment or anger
  • 16. Worry about the future or current situation you are in (finances, health, work, family, lack of purpose, lack of certainty)
  • 17. Current level of stress

  • Adrenal Glands

  • 18. Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
  • 19. Brain fog, forgetting basic things, a sense of mild confusion Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
  • 20. Unexplained anxiety
  • 21. Low or high blood pressure
  • 22. Troubles falling asleep and/or wakes up after 2-4 hours of sleep and unable to fall back asleep within 30 minutes
  • 23. Alternating areas of pain, tenderness, hot, sore, and sensitive to the touch or diagnosed with chronic fatigue syndrome or fibromyalgia

  • Thyroid Gland

  • 24. Hands and feet frequently feel cold or chilled
  • 25. Constantly feeling sleepy
  • 26. Feel slow-moving, sluggish
  • 27. Constipated regularly
  • 28. Dry or scaly skin
  • 29. Hair feels coarse and/or brittle
  • 30. Losing hair and/or outer third of eyebrow
  • 31. Heavy menstrual periods (men answer no)
  • 32. Weight gain despite changes in diet
  • 33. Take thyroid medication

  • Female Hormones

    All women please answer the following questions, even women who have had hysterectomy or have gone through menopause, please answer all the questions as if you were still having your cycle.
  • 1. Anxious, irritable, aggressive or hostile
  • 2. Breast tenderness, swelling
  • 3. Being easily overwhelmed, sad, excessively irritable or irrational
  • 4. Abnormally heavy or scanty flow, pain with cycle, periods occur irregulary or absent (not in menopause), diagnosed with fibroids, endometresosis, ovarian cysts or fibroids
  • 5. Pain when you ovulate
  • 6. Menstrual blood is dark and clots are present
  • 7. Troubles getting pregnant
  • 8. Sexual intercourse is uncomfortable
  • 9. Increased growth of dark facial and/or body hair
  • 10. Interest in having sex is low
  • 11. Had a hysterectomy, uterine ablations, D&C for heavy bleeding
  • 12. Hot flashes or spontaneous sweating

  • Stomach Function

  • 39. Indigestion, taste or burp food hours after eating
  • 40. Low iron/anemia
  • 41. Use antacids or take medications for digestion

  • Gastrointestinal Inflammation

  • 42. Feel a sense of nausea when you eat or before you eat
  • 43. Stomach pain relieved by eating food, drinking carbo-nated beverages, milk, or taking antacids
  • 44. Indigestion after eating may be 30 to 90 minutes after eating
  • 45. Muscle twitching

  • Small Intestines and Pancreas

  • 46. Pain under your rib cage on your left side
  • 47. Indigestion is delayed, occurring 2-4 hours after eating a meal
  • 48. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
  • 49. Excessive odor with bowel movements
  • 50. Undigested food in your bowel movements
  • 51. Diarrhea or frequently loose stools

  • Large intestines

  • 52. Discomfort, pain or cramps in your lower abdominal area
  • 53. Eating raw fruits and vegetables causes gas, bloating, and pain in lower abdomen
  • 54. Anal itch

  • Gallbladder

  • 55. Bowel movements alternate from normal to clay colored
  • 56. Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side
  • 57. History of gallstones or attacks, had gallbladder removed (if yes answer severe)

  • Nutritional Deficiency

  • 58. Muscle cramping
  • 59. Ridges on nails, longitudinal
  • 60. Gingivitis, gums bleeding
  • 61. Anorexia or bulimia
  • 62. Cracking/peeling/brittle/splitting fingernails or fingertips (i.e. hang nails)
  • 63. Small bumps on back of upper arms and/or thighs

  • Immune Function

  • 64. Suffer from eczema, psoriasis, lupus, MS, RA, Crohn’s or any other autoimmune condition
  • 65. Recurrent thrush or fungal infections
  • 66. Used intravenous antibiotics to clear infection or taken antibiotics for more than 30 days continuously
  • 67. Frequency of sinus, ear, yeast, kidney, bladder, skin and lung infections
  • 68. Frequent colds or flu
  • 69. Suffer from allergies

  • Detoxification system

  • 70. Currently taking statin medication or history/currently elevated cholesterol
  • 71. Suffer from acne, liver spots, or other skin lesions
  • 72. Suffer migraines and/or headaches frequently
  • 73. Bitter or metallic taste
  • 74. Difficulty recalling commonly used words
  • 75. Excessively strong body odor
  • 76. Yellowish tint of the whites of your eyes
  • 77. Dark circles around your eyes

  • Please list your top 5 complaints. If you don’t have 5 that is okay.

  • Contact Information

  • Should be Empty: