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

 

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

Feel tired in the morning despite sufficient hours of sleep

Yes / No

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

Yes / No

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

Yes / No

Feel more energetic in the late afternoon and early evening

Yes / No

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

Yes / No

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

Yes / No

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

Yes / No

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

Yes / No

Acne

Yes / No

Reliance on stimulants like caffeine & cookies  

Yes / No

Cravings for carbohydrates or sugars

Yes / No

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

Yes / No

Intolerance to cold

Yes / No

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

Reduced sex drive

Yes / No

Constipation and/or diarrhea

Yes / No

Frequently and easily overwhelmed 

Yes / No

Recurrent Candida (yeast) infections 

Yes / No

Increased frequency of urination

Yes / No

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

Yes / No

Tendency to physically tremble when under pressure

Yes / No

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

Yes / No

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

Pain in the upper back or neck with no apparent reasons

Yes / No

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

Yes / No

Cold extremities (fingers, toes, legs, arms)

Yes / No

Indigestion/gas/heartburn

Yes / No

Panic attacks

Yes / No

Bed wetting

Yes / No

Rheumatoid arthritis

Yes / No

Post-nasal drip

Yes / No

Heart palpitations 

Yes / No

Hepatitis C  

Yes / No

Do you feel overworked and under supported? 

Yes / No

Are you waking up in the morning thinking anxious thoughts?

Yes / No

Have you experienced a heartbreak in the past year?
(Death, Desertion, Divorce)  

Yes / No

Are you struggling in an unhealthy relationship with a partner's disease or compulsive behavior? (Or your own?)

Yes / No

In the past year have you experienced a major life change?
(Moved, new baby, marriage, promotion, bankruptcy, physical injury or disability?)

Yes / No

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

Yes / No