Biotics Research Assessment Form
Full Name
*
First Name
Last Name
What is your age?
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Email Address
*
example@example.com
Any of the following medications you are taking:
Antacids (Turns, etc.)
Cholesterol Medication
Hormones
Antibiotic/Antifungal
Cortisone Anti-inflammatories
Laxatives
Antidepressants
Diuretics
Lithium
Antidiabetic/Insulin
Heart Medications
Oral Contraceptives
Aspirin/Tylenol
High Blood Pressure Medications
Radiation
Chemotherapy
Relaxants/Sleeping Pills
Recreational Drugs
Thyroid
Ulcer Medications
Are you eating or drinking the following:
Alcohol (beer, wine)
Candy
Carbonated Beverages
Cigarettes
Coffee
Distilled Water
Luncheon Meals
Fluoridated/Chlorinated Water
Margarine
At fast food restaurants regularly
Refined Sugars
Non-Herbal Teas
Chew Tobacco
Vitamins & Minerals
Fried Foods
Milk Products
Refined (White) Flour Products
Artificial Sweeteners
If the following is true:
Gluten Sensitivity
Chinese food or salad bars make you ill?
Celiac's Disease
Do you get hives or headaches from drinking wine?
If the following is true:
Diet often
Salt food without tasting
Exercise less than 3 times weekly
Are exposed to chemicals at work
Are under excessive stress
Are exposed to cigarette smoke
Directions for the following questions:
Never Mild = Occurs once a month Moderate = Occurs several time a month Severe = Aware of it almost constantly
Category I - Section A
Never
Mild
Moderate
Severe
Bad breath, halitosis
1
2
3
4
Loss of taste for high protein foods
5
6
7
8
Burning (“acid”) or nervous stomach
9
10
11
12
Gas shortly after eating
13
14
15
16
Indigestion 30 to 60 mins after eating
17
18
19
20
Diffucult digesting fruits & vegetables
21
22
23
24
Acid or spicy foods upset stomach.
25
26
27
28
Category I - Section B
Never/No
Mild
Moderate
Severe
Lower bowel gas and/or bloating several hours after eating
29
30
31
32
Feet burn
33
34
35
36
Whites of eyes (sclera) yellow
37
38
39
40
Dry skin, itchy feet and/or skin
41
42
43
44
Brown spots or bronzing of skin
45
46
47
48
Bitter metallic taste in mouth
49
50
51
52
Blurred vision
53
54
55
56
Headache over eyes
57
58
59
60
Feel nauseous, queasy or gas easily
61
62
63
64
Color of stools light brown or yellow
65
66
67
68
Greasy or high fat foods cause distress
69
70
71
72
Pain between shoulder blades
73
74
75
76
Dark circles under eyes
77
78
79
80
“Acid” breath
81
82
83
84
History of gallbladder attacks or gallstones
85
86
87
88
Gallbladder removed
89
90
91
92
Appetite reduced
93
94
95
96
Category I - Section C
Never
Mild
Moderate
Severe
Coated tongue or “fuzzy” debris on tongue
97
98
99
100
Pass large amounts of foul smelling gas
101
102
103
104
Irritable bowl or mucous colitis
105
106
107
108
Constipation, diarrhea alternating or stools alternate from soft to watery
109
110
111
112
Bowel movements painful or difficult, constipation and/or laxatives used
113
114
115
116
Burning or itching anus
117
118
119
120
Category II
Never
Mild
Moderate
Severe
Head congestion sinus fullness
121
122
123
124
Sneezing attacks
125
126
127
128
Dreaming, nightmare-like bad dreams
129
130
131
132
Milk products and/or wheat products cause distress
133
134
135
136
Eyes and nose watery
137
138
139
140
Eyes swollen and puffy
141
142
143
144
Pulse speeds after meals and/or heart pounds after retiring
145
146
147
148
Category III - Section A
Never
Mild
Moderate
Severe
Crave sweets or coffee in afternoon or mid morning
149
150
151
152
Hungry between meals or excessive appetite
153
154
155
156
Overeating sweets upsets stomach
157
158
159
160
Eat when nervous
161
162
163
164
Irritable before meals
165
166
167
168
Get “shaky” or light-headed if meals delayed
169
170
171
172
Fatigue, eating relieves
173
174
175
176
Heart palpitates if meals are missed or delayed
177
178
179
180
Awaken a few hours after sleep, hard to get back to sleep
181
182
183
184
Category III - Section B
Never/No
Mild
Moderate
Severe
Muscle soreness after moderate exercise
185
186
187
188
Vulnerability to insect bites (fleas and mosquitoes)
189
190
191
192
Loss of muscle tone or “heaviness” in arms or legs
193
194
195
196
Enlarged heart and/or heart failure
197
198
199
200
Worrier, feel insecure and/or highly emotional
201
202
203
204
Pulse slow/below 65 or irregular pulse
205
206
207
208
Category IV - Section A
Never
Mild
Moderate
Severe
Sex drive increased
209
210
211
212
“Splitting” type headaches
213
214
215
216
Memory failing
217
218
219
220
Tolerance for sugar reduced
221
222
223
224
Category IV - Section B
Never
Mild
Moderate
Severe
Sex drive reduced or absent
225
226
227
228
Abnormal thirst
229
230
231
232
Weight gain around hips or waist
233
234
235
236
Tendency to ulcers or colitis
237
238
239
240
Increased ability to eat sugar without symptoms
241
242
243
244
Menstrual disorders (women)
245
246
247
248
Lack of menstruation (young girls)
249
250
251
252
Category IV - Section C
Never
Mild
Moderate
Severe
Difficulty gaining weight, even if large appetite
253
254
255
256
Heart palpitations
257
258
259
260
Nervous, emotional, and/or can't work under pressure
261
262
263
264
Insomnia
265
266
267
268
Inward trembling
269
270
271
272
Night sweats
273
274
275
276
Fast pulse at rest
277
278
279
280
Intolerant to high temperatures
281
282
283
284
Easily flushed
285
286
287
288
Category IV - Section D
Never
Mild
Moderate
Severe
Difficulty losing weight
289
290
291
292
Reduced initiative and/or mental sluggishness
293
294
295
296
Easily fatigued, sleepy during the day
297
298
299
300
Sensitive to cold, poor circulation (cold hands and feet)
301
302
303
304
Dry or scaly skin
305
306
307
308
“Ringing” in ears/noise in head
309
310
311
312
Hearing impaired
313
314
315
316
Constipation
317
318
319
320
Excessive falling hair and/or coarse hair
321
322
323
324
Headaches when awaken/wear off during the day
325
326
327
328
Category IV - Section E
Never
Mild
Moderate
Severe
Blood pressure increased
329
330
331
332
Headaches
333
334
335
336
Hot flashes
337
338
339
340
Hair growth on face or body (females)
341
342
343
344
Masculine tendencies (females)
345
346
347
348
Category IV - Section F
Never
Mild
Moderate
Severe
Blood pressure low
349
350
351
352
Crave salt
353
354
355
356
Chronic fatigue/get drowsy
357
358
359
360
Afternoon yawning
361
362
363
364
Weakness/dizziness
365
366
367
368
Weakness after colds/slow recovery
369
370
371
372
Circulation poor
373
374
375
376
Muscular and nervous exhaustions
377
378
379
380
Subject to colds, asthma, bronchitis (respiratory disorders)
381
382
383
384
Allergies and/or hives
385
386
387
388
Difficulty maintaining manipulative correction
389
390
391
392
Arthritic tendencies
393
394
395
396
Nails weak, ridged
397
398
399
400
Perspire easily
401
402
403
404
Slow starter in morning
405
406
407
408
Afternoon headaches
409
410
411
412
Category V - Section A
Never/No
Mild
Moderate
Severe
Frequent skin rashes and/or hives
413
414
415
416
Muscle-leg-toe cramping at rest or while sleeping
417
418
419
420
Fever easily raised/fevers common
421
422
423
424
Crave chocolate
425
426
427
428
Feet have bad odor
429
430
431
432
Hoarseness frequent
433
434
435
436
Difficulty swallowing
437
438
439
440
Joint stiffness after rising
441
442
443
444
Vomiting frequent
445
446
447
448
Tendency to anemia
449
450
451
452
"Whites” of eyes (sclera) blue
453
454
455
456
“Lump” in throat
457
458
459
460
Dry mouth-eyes-nose
461
462
463
464
White spots on finger nails
465
466
467
468
Cuts heal slowly and/or scar easily
469
470
471
472
Reduced or “lost” sense of taste and/or smell
473
474
475
476
Susceptible to colds, fevers, and/or infections
477
478
479
480
Strong light irritates eyes
481
482
483
484
Noises in head or ringing in ears
485
486
487
488
Burning sensations in mouth
489
490
491
492
Numbness in hands and feet (extremities “go to sleep")
493
494
495
496
Intolerant to monosodium glutamate (MSG)
497
498
499
500
Cannot recall dreams
501
502
503
504
Nose bleeds frequent
505
506
507
508
Bruise easily, “black and blue” spots
509
510
511
512
Muscle cramps. Worse with exercise
513
514
515
516
Category VI
Never
Mild
Moderate
Severe
Aware of heavy and/or irregular breathing
517
518
519
520
Discomfort in high altitudes
521
522
523
524
“Air hunger"/sigh frequently
525
526
527
528
Swollen ankles/worse at night
529
530
531
532
Shortness of breath with exertion
533
534
535
536
Dull pain in chest and/or pain radiating into left arm, worse on exertion
537
538
539
540
Category VII - Female Only
Never/No
Mild
Moderate
Severe
Premenstrual tension
541
542
543
544
Painful menses (cramping, etc.)
545
546
547
548
Menstruation excessive or prolonged
549
550
551
552
Painful/tender breasts
553
554
555
556
Menstruate too frequently
557
558
559
560
Acne, worse at menses
561
562
563
564
Depressed feelings before menstruation
565
566
567
568
Vaginal discharge
569
570
571
572
Menses scanty or missed
573
574
575
576
Hysterectomy/ovaries removed
577
578
579
580
Menopausal hot flashes
581
582
583
584
Depression
585
586
587
588
Category VIII - Male Only
Never
Mild
Moderate
Severe
Prostate trouble
589
590
591
592
Urination difficulty or dribbling
593
594
595
596
Night urination frequent
597
598
599
600
Pain on inside of legs or heels
601
602
603
604
Feeling of incomplete bowel evacuation
605
606
607
608
Leg nervousness at night
609
610
611
612
Tire easily/avoid activity
613
614
615
616
Reduced sex drive
617
618
619
620
Depression
621
622
623
624
Migrating aches and pains
625
626
627
628
List any vitamins/supplements you are currently taking:
Do you have any medication allergies?
Yes
No
Do you use any kind of tobacco or have you ever used them?
Yes
No
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