1.  How do you feel right now? Circle One:
Tired     O.K      Fine     Good     GREAT

 

2.  How do you normally feel? Circle One: 
 

Tired
O.K
Good   GREAT

3.  Feel tired in the morning despite sufficient hours of sleep

Yes / No

4.  Difficulty getting up in the morning, even though you are a "morning person"
 

Yes / No

5.  Feel fatigued in the afternoon, especially between 3-5 p.m.

Yes / No

6.  Feel more energetic in the late afternoon and early evening

Yes / No

7. Insomnia/irregular sleep - fatigued at night but wake up often

Yes / No

8. Weight gain and can't lose it, especially around the waist

Yes / No

9. Depression for no particular reason, as well as for particular reasons 

Yes / No

10. Hair loss (10-20 hairs in your brush or comb)

Yes / No

11. Acne

Yes / No

12. Reliance on stimulants like caffeine & cookies ... Can't get going without them ...  
 

Yes / No

13. Cravings for carbohydrates or sugars

Yes / No

14. Memory or concentration problems – feeling foggy, “spaced” out & lost

Yes / No

15. Intolerance to cold

Yes / No

16. Hypersensitivity to light/sound/touch/odors (ex. the sound of the bathroom fan, even with the door closed used to drives me nuts!)

Yes / No

17. Reduced to non-existent sex drive

Yes / No

18. Constipation and/or diarrhea
Constipation is having less than 2 bowel movements a day.

Yes / No

19. Frequently feel overwhelmed, angry and resentful? 

Yes / No

20. Recurrent Candida (yeast) infections 

Yes / No

21. Increased frequency of urination

Yes / No

22. Increased frequency in illness, particularly the flu and other respiratory diseases; symptoms tend to last longer than usual

Yes / No

23. Tendency to physically tremble when under pressure

Yes / No

24. Crave salty, fatty, and high protein foods such as potato chips, meat and cheese

Yes / No

25. Increased symptoms of PMS for women; periods are heavy and then stop, or almost stopped on the 4th day, only to start flow again on the 5th or 6th day

Yes / No

26. Pain in the upper back or neck with no apparent reasons

Yes / No

27. Feel physically better when stress is relieved, such as on a vacation

Yes / No

28. Cold extremities (fingers, toes, legs, arms)

Yes / No

29. Indigestion/gas/heartburn

Yes / No

30. Panic attacks

Yes / No

31. Do you feel overworked and under supported? 

Yes / No

32. Waking up in the morning thinking anxious thoughts

Yes / No

33. Experienced a heartbreak in the past year.
(Death, Desertion, Divorce)  

Yes / No

34. Struggling in an unhealthy relationship with a partner's disease or compulsive behavior. (Or your own.)

Yes / No

35. Have you, in the past year, experienced a major life change.
(Moved, new baby, marriage, promotion, bankruptcy, physical injury or disability?)

Yes / No

36. Do you feel disconnected from God?

Yes / No

37. Do you feel disconnected from your body?
Little or no desire to exercise, pamper or enjoy.

Yes / No

38. Do you have a difficult time asking for help?
 

Yes / No

39. Over the past 6 months have you stopped or cut way back on time spent with family, friends and favorite organizations? Are you
spending more time isolating from the world? 
 

Yes / No

40. Are you ready to end your denial, stop helping everyone BUT yourself AND start taking care of YOU? 

Hope so. For your sake, and theirs. (Scroll On Down ...)
 

Yes / No