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

 

2.  How do you normally feel? Circle One: 
(Now notice & note how you feel everyday for one week to see
if  your answer is accurate or if you are in denial.)

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, drives me nuts!)
 Have taken antibiotic drugs for acne or respiratory, urinary or other infections four or more times in a one-year period

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. Bed wetting

Yes / No

32. Rheumatoid arthritis

Yes / No

33. Post-nasal drip

Yes / No

34. Heart palpitations 

Yes / No

35. Hepatitis C  

Yes / No

36. Do you feel overworked and under supported? 

Yes / No

37. Waking up in the morning thinking anxious thoughts

Yes / No

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

Yes / No

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

Yes / No

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

Yes / No

41. Do you feel disconnected from God, your spirituality?

Yes / No

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

Yes / No

43. Do you have a difficult time asking for help?
Do you know you need help?

Yes / No

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

Yes / No

45. 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