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1. Foul smelling stools - worse in afternoon and evening
Yes
No
Sometimes
2. Itching around the anus, especially at night
Yes
No
Sometimes
3.Grinding teeth during sleep
Yes
No
Sometimes
4. Have taken a broad-spectrum antibiotic
Yes
No
Sometimes
5. Alternating constipation diarrhea
Yes
No
Sometimes
6. Whitish coating on tongue
Yes
No
Sometimes
7. Eyes overly sensitive to sunshine or bright light
Yes
No
Sometimes
8. Episodes of dizziness or blacking out upon standing
Yes
No
Sometimes
9. Wake too early in the morning, such as 3 or 4 am
Yes
No
Sometimes
10. Cold hands and feet
Yes
No
Sometimes
11. Temperature less than 98.6 F
Yes
No
Sometimes
12. Gain weight easily or hard time losing it
Yes
No
Sometimes
13. Fats / greasy foods cause nausea or headaches
Yes
No
Sometimes
14. Skin peels on soles of feet
Yes
No
Sometimes
15. Dandruff or itchy scalp
Yes
No
Sometimes
16. Gas, belching, or burping immediately after meals
Yes
No
Sometimes
17. Abdominal bloating or distension
Yes
No
Sometimes
18. Nausea after taking supplements
Yes
No
Sometimes
19. Stomach pain relieved by drinking milk
Yes
No
Sometimes
20. Hot or spicy foods cause stomach irritation
Yes
No
Sometimes
21. Depression
Yes
No
Sometimes
22. Dry eyes or frequent chapped lips
Yes
No
Sometimes
23. High blood pressure or clogging of arteries
Yes
No
Sometimes
24. Ancestry that is ¼ or more Celtic Irish, Scandinavian, Native American, Welsh, or Scottish
Yes
No
Sometimes
25. Family history of alcoholism, depression, suicide, schizophrenia, or other mental illness
Yes
No
Sometimes
26. Winter depression that lifts or lightens in the sunny springtime
Yes
No
Sometimes
27. I have hard, difficult to pass bowel movements once a day or less
Yes
No
Sometimes
28. I use garden chemicals or treat with insecticides or have exposure to toxins in the workplace
Yes
No
Sometimes
29. I frequently experience one of the following: headache, sore throat, muscle aches, colds or flu
Yes
No
Sometimes
30. I have been on prescription medications for some time
Yes
No
Sometimes
31. My stool frequently has a foul odor or I often have bad breath or body odor
Yes
No
Sometimes
32. I have one or more of the following: skin tags or rashes, sneezing attacks, excessive mucous
Yes
No
Sometimes
Additional Questions for Females
33. Loss of scalp hair
Yes
No
Sometimes
34. Oily skin, acne
Yes
No
Sometimes
35. Increased facial hair
Yes
No
Sometimes
36. Low sex drive
Yes
No
Sometimes
37. Vaginal dryness
Yes
No
Sometimes
38. Memory lapses or foggy thinking
Yes
No
Sometimes
39. PMS
Yes
No
Sometimes
40. Painful or lumpy breasts
Yes
No
Sometimes
41. White spots on fingernails
Yes
No
Sometimes
42. Night sweats
Yes
No
Sometimes
43. Hot flashes
Yes
No
Sometimes
44. Painful intercourse or vaginal dryness
Yes
No
Sometimes
45. Tender breasts
Yes
No
Sometimes
46. Water retention or puffiness
Yes
No
Sometimes
47. Heavy Menstruation
Yes
No
Sometimes
Enter additional comments, if any:
SU BMIT
