Comprehensive Health Evaluation
Serotonin
1. Feel depressed, unhappy, or sad
No
Mild
Moderate
Severe
2. You can’t stay asleep and/or lack of deep restorative sleep
No
Mild
Moderate
Severe
3. Compulsive behavior, unprovoked anger and/or unexplained crying
No
Mild
Moderate
Severe
Serotonin %
Dopamine
4. Feel anxious or have social phobia
No
Mild
Moderate
Severe
5. Have addictive personality; Past/present troubles with alcohol, food, pharmaceutical and recreational drugs.
No
Mild
Moderate
Severe
6. Have troubles staying focused on one particular task
No
Mild
Moderate
Severe
7. Life seems less fun, colorful or flavorful, lack pleasure
No
Mild
Moderate
Severe
Dopamine %
Acetylcholine
8. Lapses in memory
No
Mild
Moderate
Severe
9. Difficulty comprehending verbal instructions
No
Mild
Moderate
Severe
Acetylcholine %
Gaba
10. Feel tense and/or have troubles turning your mind off when you want to relax
No
Mild
Moderate
Severe
11. Feel irritable, crabby or short tempered
No
Mild
Moderate
Severe
12. You often use alcohol or other sedatives to calm down
No
Mild
Moderate
Severe
Gaba %
Stress
13. Feelings of hopelessness
No
Mild
Moderate
Severe
14. Feelings of being overwhelmed
No
Mild
Moderate
Severe
15. Events from the past cause you pain, resentment or anger
No
Mild
Moderate
Severe
16. Worry about the future or current situation you are in (finances, health, work, family, lack of purpose, lack of certainty)
No
Mild
Moderate
Severe
17. Current level of stress
No
Mild
Moderate
Severe
Stress %
Nervous System Total %
Adrenal Glands
18. Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
No
Mild
Moderate
Severe
19. Brain fog, forgetting basic things, a sense of mild confusion Stress seems to easily cause noticeable symptoms like flushing or heart palpitations
No
Mild
Moderate
Severe
20. Unexplained anxiety
No
Mild
Moderate
Severe
21. Low or high blood pressure
No
Mild
Moderate
Severe
22. Troubles falling asleep and/or wakes up after 2-4 hours of sleep and unable to fall back asleep within 30 minutes
No
Mild
Moderate
Severe
23. Alternating areas of pain, tenderness, hot, sore, and sensitive to the touch or diagnosed with chronic fatigue syndrome or fibromyalgia
No
Mild
Moderate
Severe
Adrenal Glands %
Thyroid Gland
24. Hands and feet frequently feel cold or chilled
No
Mild
Moderate
Severe
25. Constantly feeling sleepy
No
Mild
Moderate
Severe
26. Feel slow-moving, sluggish
No
Mild
Moderate
Severe
27. Constipated regularly
No
Mild
Moderate
Severe
28. Dry or scaly skin
No
Mild
Moderate
Severe
29. Hair feels coarse and/or brittle
No
Mild
Moderate
Severe
30. Losing hair and/or outer third of eyebrow
No
Mild
Moderate
Severe
31. Heavy menstrual periods (men answer no)
No
Mild
Moderate
Severe
32. Weight gain despite changes in diet
No
Mild
Moderate
Severe
33. Take thyroid medication
No
Yes
Thyroid Gland %
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
No
Mild
Moderate
Severe
2. Breast tenderness, swelling
No
Mild
Moderate
Severe
3. Being easily overwhelmed, sad, excessively irritable or irrational
No
Mild
Moderate
Severe
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
No
Mild
Moderate
Severe
5. Pain when you ovulate
No
Mild
Moderate
Severe
6. Menstrual blood is dark and clots are present
No
Mild
Moderate
Severe
7. Troubles getting pregnant
No
Mild
Moderate
Severe
8. Sexual intercourse is uncomfortable
No
Mild
Moderate
Severe
9. Increased growth of dark facial and/or body hair
No
Mild
Moderate
Severe
10. Interest in having sex is low
No
Mild
Moderate
Severe
11. Had a hysterectomy, uterine ablations, D&C for heavy bleeding
No
Mild
Moderate
Severe
12. Hot flashes or spontaneous sweating
No
Mild
Moderate
Severe
Female Hormones %
Hormonal System Total (Female) %
Stomach Function
39. Indigestion, taste or burp food hours after eating
No
Mild
Moderate
Severe
40. Low iron/anemia
No
Yes
41. Use antacids or take medications for digestion
Never
Once or twice weekly
Three to five times weekly
Daily
Stomach Function %
Gastrointestinal Inflammation
42. Feel a sense of nausea when you eat or before you eat
No
Mild
Moderate
Severe
43. Stomach pain relieved by eating food, drinking carbo-nated beverages, milk, or taking antacids
No
Mild
Moderate
Severe
44. Indigestion after eating may be 30 to 90 minutes after eating
No
Mild
Moderate
Severe
45. Muscle twitching
No
Mild
Moderate
Severe
Gastrointestinal Inflammation %
Small Intestines and Pancreas
46. Pain under your rib cage on your left side
No
Mild
Moderate
Severe
47. Indigestion is delayed, occurring 2-4 hours after eating a meal
No
Mild
Moderate
Severe
48. The consistency or form of your stool changes (e.g., from narrow to loose) within the course of a day
No
Mild
Moderate
Severe
49. Excessive odor with bowel movements
No
Mild
Moderate
Severe
50. Undigested food in your bowel movements
No
Mild
Moderate
Severe
51. Diarrhea or frequently loose stools
No
Mild
Moderate
Severe
Small Intestines and Pancreas %
Large intestines
52. Discomfort, pain or cramps in your lower abdominal area
No
Mild
Moderate
Severe
53. Eating raw fruits and vegetables causes gas, bloating, and pain in lower abdomen
No
Mild
Moderate
Severe
54. Anal itch
No
Mild
Moderate
Severe
Large intestines %
Gallbladder
55. Bowel movements alternate from normal to clay colored
No
Mild
Moderate
Severe
56. Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side
No
Mild
Moderate
Severe
57. History of gallstones or attacks, had gallbladder removed (if yes answer severe)
No
Mild
Moderate
Severe
Gallbladder %
Nutritional Deficiency
58. Muscle cramping
No
Mild
Moderate
Severe
59. Ridges on nails, longitudinal
No
Mild
Moderate
Severe
60. Gingivitis, gums bleeding
No
Mild
Moderate
Severe
61. Anorexia or bulimia
Never
Within last 5 years
Within last 2-5 years
Currently or within last 2 years
62. Cracking/peeling/brittle/splitting fingernails or fingertips (i.e. hang nails)
No
Mild
Moderate
Severe
63. Small bumps on back of upper arms and/or thighs
No
Mild
Moderate
Severe
Nutritional Deficiency %
Immune Function
64. Suffer from eczema, psoriasis, lupus, MS, RA, Crohn’s or any other autoimmune condition
No
Yes
65. Recurrent thrush or fungal infections
No
Yes
66. Used intravenous antibiotics to clear infection or taken antibiotics for more than 30 days continuously
No
Yes
67. Frequency of sinus, ear, yeast, kidney, bladder, skin and lung infections
None
2 to 3 times per year
4 to 5 times per year
6 or more times per year
68. Frequent colds or flu
None
2 to 3 times per year
4 to 5 times per year
6 or more times per year
69. Suffer from allergies
Never
Rarely
Occasionally
Often
Immune Function %
Digestive System Total %
Detoxification system
70. Currently taking statin medication or history/currently elevated cholesterol
No
Yes
71. Suffer from acne, liver spots, or other skin lesions
No
Mild
Moderate
Severe
72. Suffer migraines and/or headaches frequently
No
Mild
Moderate
Severe
73. Bitter or metallic taste
No
Mild
Moderate
Severe
74. Difficulty recalling commonly used words
No
Mild
Moderate
Severe
75. Excessively strong body odor
No
Mild
Moderate
Severe
76. Yellowish tint of the whites of your eyes
No
Mild
Moderate
Severe
77. Dark circles around your eyes
No
Mild
Moderate
Severe
Detoxification System %
Total Wellness Score %
Please list your top 5 complaints. If you don’t have 5 that is okay.
1
2
3
4
5
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