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| Please select yes or no for each of the following questions. Please fill in the Other sections for any unlisted issues related to each category. |
Do you experience
symptoms of hypoglycemia
such as dizziness,
shakiness or brain fog
between or following
meals? |
|
Do you frequently miss or
delay meals? |
|
Do you frequently crave
sugar or carbohydrates? |
|
Do you consume excessive
sugar or refined
carbohydrates? |
|
Are you diabetic or
pre-diabetic? |
|
Do you regularly consume
alcohol or caffeine? |
|
Do you consume food
within two hours before
bedtime? |
|
Regarding Blood Sugar
Imbalance - Other? |
|
Do you frequently
experience anxiety? |
|
Do you suffer from
depression? |
|
Do you suffer from mood
swings? |
|
Do you have difficulty
getting motivated? |
|
Do you frequently
experience feelings of
agitation, anger, fear or
worry? |
|
Do you consider your job,
relationships or finances
stressors in your daily
life? |
|
Are you a caregiver for a
parent or disabled child? |
|
Mental and Emotional
Stress - Other? |
|
Are you experiencing
problems falling asleep? |
|
Are you experiencing
difficulty staying
asleep? |
|
Are you sleeping for 7-9
hours each night? |
|
Do you feel well-rested
when you wake up in the
morning? |
|
Do you work 2nd or 3rd
shift or keep late night
hours? |
|
Do you block blue light
from your eyes at least
two hours before bed? |
|
Do you eat within two
hours of bedtime? |
|
Do you frequently feel
drowsy throughout the
day? |
|
| Do you snore? |
|
Sleep Cycle Disturbances
- Other? |
|
Musculoskeletal: Do you
suffer from headaches,
muscle, back or joint
pain? |
|
Gastrointestinal: Do you
suffer from IBS,
Crohnu2019s disease or
diverticulitis? |
|
Dermatological: Do you
suffer from hives, eczema
or psoriasis? |
|
Respiratory: Do you
suffer from asthma,
bronchitis, seasonal
allergies or hay fever? |
|
Autoimmune: Do you suffer
from any autoimmune
condition such as MS,
lupus or rheumatoid
arthritis? |
|
Immunological: Do you
suffer from food
allergies, chronic
infections or frequent
Illness? |
|
Inflammatory Imbalance or
Chronic Pain - Other? |
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Disclaimer: This tool does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read here or anywhere online. If you think you may have a medical emergency, immediately call your doctor or dial 911. |