Name
*
First Name
Last Name
Email
*
Feeling depressed and/or anxious
*
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Feeling “tired but wired”
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Difficulty waking or feeling fatigued, even after a full night’s sleep
*
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Loss of, brittle, or slow-growing hair and/or nails
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Dry, itchy, or thin skin
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
High or low blood pressure
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Easily distracted; have a poor memory or difficulty finding the right words
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Experience frequent or intense mood swings
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Difficulty falling asleep or sleeping through the night
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Hot flashes or excessive sweating during the day or at night
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Frequent sore throat (not related to illness), hoarseness, or loss of voice
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Total Score of Section One
Frequent headaches or migraines
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Constipation (bowels don’t move daily) or difficult bowel movements
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Poor appetite and/or unexplained weight loss
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Suffer from an inflammatory bowel condition
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Experience gas, bloating, or belching after eating
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Inability to loose weight; carry excess body fat
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Experience indigestion or acid reflux after eating
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Visual difficulties
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Hair loss
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Foggy thinking or difficulty concentrating;
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Total Score of Section Two
Hives, eczema, asthma, chronic cough, or seasonal allergies
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Wounds or injuries don’t heal quickly or completely
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Dry, itchy, or watery eyes
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Susceptible to colds and/or flus
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Cold or tingling in the hands or feet
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Sensitive to the sun
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Decrease in athletic performance or difficulty achieving and maintaining fitness
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Poor mobility and/or agility; stiff or limited movement
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Feeling sore all over; aching muscles or joints
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Bags or dark circles under the eyes
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Total Score of Section Three
Cravings for caffeine, sugar, and/or chocolate
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Cravings for fatty or salty foods
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Tendency to carry excess weight around the midsection
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Frequently hungry during the day
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Cravings for starchy carbohydrates like bread, pasta, and cereal
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Often wake hungry during the night
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Often feel "hangry" (hungry + angry or irritable)
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Feel colder than those around you
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
High or low blood sugar
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Tend to "bonk" during endurance activity
1 Never
2 Mild or infrequent
3 Moderate or often
4 Severe or constant
Total Score of Section Four
TOTAL SCORE OF ALL FOUR SECTIONS
