DA
Fax your answers to 979-776-6280
In the last year, I have experienced following problems.
Your truthful answers will help me understand the state your body and brain are in.
Please circle each that applies to you.
1. I have low or no energy through the day.
2. I lack desire for activity, projects or challenging things.
3. I want to but cannot go on with exercise.
4. I have low concentration and attention.
5. I sleep too much.
6. I have problems waking up in the morning.
7. I have low sexual desire and drive
8. I use caffeine, chocolate, diet pills, Red Bulls, energy drinks to keep awake.
9. I use methamphetamines, Cocaine or use stimulants (Medicines like Ritalin, Adderall, Concerta, Vyvance, Provigil, Nuvigil) to keep awake.
10. I am a pessimist.
11. I have lot of thoughts that I am a failure. I blame my self for small little things that others can ignore.
12. I have low self-esteem.
13. I do not have self-confidence.
14. I have absurd thoughts or images that bother me. (e.g. Unwanted sexual, aggressive thoughts or images)
15. I get moody and depressed in fall or winter, as day light becomes shorter.
16. My family has history of seasonal affective disorder.
17. I am irritable, and easily angered.
18. I am impatient.
19. I am a perfectionist.
20. I am socially shy and get anxious when in group of people.
21. I am fearful of going out of my “safe zone” like my house or family.
22. I have fear of heights, crowds, or flying.
23. I have fear of speaking in public.
24. I feel anxious or have panic attacks (feeling of doom)
25. I have PMS (premenstrual syndrome) with moodiness, cravings, breast tenderness, swelling and bloating before my period.
26. I have problems falling asleep.
27. I wake up in the middle of the night and have trouble getting back to sleep.
28. I wake up too early in the morning.
29. I crave sweets or starchy carbs like bread and pasta.
30. I feel good when I exercise.
31. I have muscle aches, jaw pain, and fibromyalgia.
32. My family members have benefited from Prozac, Zoloft or similar medications.
33. I am nervous and cannot relax.
34. I feel frequently feel overworked or pressured.
35. I stress out easily.
36. I ma easily overwhelmed.
37. My muscles get tense and uptight.
38. Frequently I have a knot in my stomach.
39. I sometimes feel weak and shaky.
40. Loud noises, lights, or excess activity by others bother me.
41. I am nervous without food.
42. I use sugar, alcohol, or drugs to relax.
43. I must make lists so I don’t forget things.
44. I can’t do math in my head.
45. I can’t remember what I was just talking about.
46. I cannot soak in the new information.
47. I can’t follow story plots.
48. I misplace common things like keys and cell phones.
49. I have trouble focusing during lectures and meetings.
50. I feel dull in my brain.
Food Table:
|Please comment below on your food habits |
|Note how frequently in a week you eat the listed items. |
|Item |once or twice a week |3-5 time week |4-5 times a week or more |
|Meat | | | |
|Dairy | | | |
|Fats (margarine, butter, packed| | | |
|food) | | | |
|Veggies | | | |
|(2-3 cupful) | | | |
|Fruits | | | |
|(2-3 cupful) | | | |
|Alcohol | | | |
In the last year, I have experienced following problems. Check 0 (No problems) to 3 (severe problems)
|Problem |0 |1 |2 |3 |
|Work inside home or office | | | | |
|Lack exposure to sunshine | | | | |
|Using sunscreen frequently | | | | |
|Weakness in muscles (sore) | | | | |
|My bones hurt | | | | |
|My mind does not feel sharp | | | | |
|I am losing short term memory | | | | |
|My diet lacks in small-fatty-fish like mackerel, herring,| | | | |
|sardine etc | | | | |
|Frequent Infections | | | | |
|Arthritis | | | | |
|My skin color |Light |Bronze |Brown |Dark |
|Age in years |>30 |>40 |>50 |>60 |
In the last year, I have experienced following problems. Check 0 (No problems) to 3 (severe problems)
|Problem |0 |1 |2 |3 |
|Brittle, thin, peeling nails | | | | |
|Nails have ridges and spots | | | | |
|Skin rashes and eczema | | | | |
|Acne | | | | |
|I don’t heal well, if cut | | | | |
|Allergies that have not improved | | | | |
|I am losing my hair prematurely | | | | |
|Frequent Dandruff | | | | |
|Frequent Diarrhea | | | | |
|My town supplies hard water | | | | |
|I don’t eat seaweed, kelp, fish, or lamb | | | | |
|I eat beans & pumpkin seeds | | | | |
|I eat ginger root | | | | |
|I take “water pills” -diuretics | | | | |
|I cannot smell or taste well | | | | |
In the last year, I have experienced following problems. Check 0 (No problems) to 3 (severe problems)
|Problem |0 |1 |2 |3 |
|Cold sensitivity is high | | | | |
|My hands and feet stay cold | | | | |
|I feel cold in summer | | | | |
|Dry, rough skin | | | | |
|My nails are thick and not shiny | | | | |
|I am losing eyebrows | | | | |
|I am tired and fatigued | | | | |
|Low blood pressure | | | | |
|I was told I have low heart rate | | | | |
|I can’t lose weight | | | | |
|I am in depressed dull Mood | | | | |
|I lack of drive to do things | | | | |
|My memory is going down | | | | |
|I am losing my sex drive | | | | |
|I retain water in my body | | | | |
|My hands and feet are swollen in the morning | | | | |
|My doctor says that have “PMS” or PMDD (for females) | | | | |
|I have heavy periods | | | | |
Before After
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