Free Online Health Assessment
Take our free online health assessment and see if our clinic is the right fit for you. Fill out all the questions below and our staff will review and respond to help you start thriving!
Name
*
First Name
Last Name
Email
*
example@example.com
Assessment Score
Category 1: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Feeling that bowels do not empty completely
Lower abdominal pain relieved by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard, dry, or small stool
Coated tongue or "fuzzy" debris on tongue
Pass large amount of foul-smelling gas
More than 3 bowel movements daily
Use laxatives frequently
Category 2: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Increasing frequency of food reactions
Unpredictable food reactions
Aches, pains, and swelling throughout the body
Unpredictable abdominal swelling
Frequent bloating and distention after eating
Abdominal intolerance to sugars and starches
Category 3: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Intolerance to smells
Intolerance to jewelry
Intolerance to shampoo, lotion, detergents, etc.
Multiple smell and chemical sensitivities
Constant skin outbreaks
Category 4: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Excessive belching, burping, or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movement
Sense of fullness during and after meals
Difficulty digesting fruits and vegetables; undigested food found in stools
Category 5: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Stomach pain, burning, or aching 1-4 hours after eating
Use antacids
Feel hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief by using antacids, food, milk, or carbonated beverages
Digestive problems subside with rest and relaxation
Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine
Category 6: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Roughage and fiber cause constipation
Indigestion and fullness last 2-4 hours after eating
Pain, tenderness, soreness on left side under rib cage
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling, mucous like, greasy, or poorly formed
Frequent urination
Increased thirst and appetite
Category 7: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Greasy or high-fat foods cause distress
Lower bowel gas and/or bloating several hours after eating
Bitter metallic taste in mouth, especially in the morning
Burpy, fishy taste after consuming fish oils
Difficulty losing weight
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored to normal brown
Reddened skin, especially palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Category 7b: Please check the appropriate answer for each question below.
*
Rows
Yes
No
Have you had your gallbladder removed?
Category 8: Please check the appropriate answer for each question below.
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Rows
Not At All
Sometimes
Very Often
Every Day
Acne and unhealthy skin
Excessive hair loss
Overall sense of bloating
Bodily swelling for no reason
Hormone imbalances
Weight gain
Poor bowel function
Excessively foul-smelling sweat
Category 9: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep going/get started
Get light-headed if meals are missed
Eating relieves fatigue
Feel shaky, jittery, or have tremors
Agitated, easily upset, nervous
Poor memory/forgetful
Blurred vision
Category 10: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst and appetite
Difficulty losing weight
Category 11: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
Category 12: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Cannot fall asleep
Perspire easily
Under high amount of stress
Weight gain when under stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with little or no activity
Category 13: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Edema and swelling in ankles and wrists
Muscle cramping
Poor muscle endurance
Frequent urination
Frequent thirst
Crave salt
Abnormal sweating from minimal activity
Alteration in bowel regularity
Inability to hold breath for long periods
Shallow, rapid breathing
Category 14: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Tired/sluggish
Feel cold—hands, feel, all over
Require excessive amounts of sleep to function properly
Increase in weight even with low calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression/lack of motivation
Morning headaches that wear off as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face, or genitals, or excessive hair loss
Dryness of skin and/or scalp
Mental sluggishness
Category 15: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Heart palpitations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats
Difficulty gaining weight
Category 16: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
Category 17: Please check the appropriate answer for each question below.
*
Rows
Not At All
Sometimes
Very Often
Every Day
Increased sex drive
Tolerance to sugars reduced
"Splitting" - type headaches
Category 18 (Males Only): Please check the appropriate answer for each question below.
Rows
Not At All
Sometimes
Very Often
Every Day
Urination difficulty or dribbling
Frequent urination
Pain inside of legs or heels
Feeling of incomplete bowel emptying
Leg twitching at night
Category 19 (Males Only): Please check the appropriate answer for each question below.
Rows
Not At All
Sometimes
Very Often
Every Day
Decreased libido
Decreased number of spontaneous morning erections
Decreased fullness of erections
Difficulty maintaining morning erections
Spells of mental fatigue
Inability to concentrate
Episodes of depression
Muscle soreness
Decreased physical stamina
Unexplained weight gain
Increase in fat distribution around chest and hips
Sweating attacks
More emotional than in the past
Category 20 (Menstruating Females Only): Please check the appropriate answer for each question below.
Rows
Yes
No
Perimenopausal
Alternating menstrual cycle lengths
Extended menstrual cycle (greater than 32 days)
Shortened menstrual cycle (less than 24 days)
Category 21 (Menstruating Females Only): Please check the appropriate answer for each question below.
Rows
Not At All
Sometimes
Very Often
Every Day
Pain and cramping during periods
Scanty blood flow
Heavy blood flow
Breast pain and swelling during menses
Pelvic pain during menses
Irritable and depressed during menses
Acne
Facial hair growth
Hair loss/thinning
Category 22 (Menopausal Females Only): Please check the appropriate answer for each question below.
Rows
Yes
No
Since menopause, do you ever have uterine bleeding
Category 23 (Menopausal Females Only): Please check the appropriate answer for each question below.
Rows
Years
How many years have you been menopausal?
Category 24 (Menopausal Females Only): Please check the appropriate answer for each question below.
Rows
Not At All
Sometimes
Very Often
Every Day
Hot flashes
Mental fogginess
Disinterest in sex
Mood swings
Depression
Painful intercourse
Shrinking breasts
Facial hair growth
Acne
Increased vaginal pain, dryness, or itching
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