ANSWER YES OR NO TO THE FOLLOWING, IF NOT SURE, LEAVE BLANK.
     
1
yes no  
Do you have low libido?
Is it hard for you to build muscle?
Do you have adult acne?
Do you have significant PMS symptoms?
Do you have trouble falling or staying asleep?
Do you have hot flashes or night sweats?
Do you have irregular or heavy menses?
     
2
yes no  
Do you suffer from anxiety?
Do you suffer from depression?
Do you have trouble focusing or staying on task?
Are you forgetful often?
Do you have low motivation or drive?
Do you have 'brain fog'?
Do you have trouble falling or staying asleep?
     
3
yes no  
Do you have heavy menses?
Are you a vegetarian or vegan?
Do you have signifigant hair loss?
Do you have cold hands and feet?
Is your tongue sore?
Do you bruise or bleed easily?
Do you crave sweets?
Do you catch any cold/flu that comes along?
Do you feel lightheaded often?
Do you have heart palpitations?
Do you get muscle cramps or spasms?
Do you have an irregular eating schedule?
Are you overweight?
Do you drink half your weight in ounces of water each day?
Do you consume sugar regularly?
Do you eat out often?
Do you get shakey or irritable if you miss a meal?
     
     
4
yes no
Are you tired in the morning even after sleeping well?
Do you get a 'second wind' of energy at night?
Do you crave salty foods?
Do you get dizzy when you stand up quickly?
Do you have a history of high stress times in your life?
Do you feel 'wired and tired'?
Are you slow to bounce back after a stressor, or after exercise?
Do you have poor sleep quality?
Is it hard for you to handle stress?
Do you skip meals often?
Do you get shakey or irritable if you miss a meal?
Do you have allergies?
5
yes no  
Do you have a bowel movement less than once per day?
Are you gassy daily?
Do you hear or feel rumbling in your abdomen after you eat?
Do you feel bloated after eating a normal amount of food?
Have you taken antibiotics more than 3 times in your life?
Do you crave sweets?
Do you have loose or unformed stools often?
Do you have itchy skin?
Do you have adult acne?
Do you eat processed foods?
Do you have abdominal pain?
Do you take anti-acids, or laxatives regularly?
     
6
yes no  
Do you have a sensitive nose and smells things others don't?
Are you chemically sensitive?
Do you get headaches in stores with perfume counters?
Have you lived in homes with mold or water leaks?
Do you have brain fog?
Are you the one who can not drink much alcohol?
Do you have an autoimmune condition?
Do you consume fish often?
Do you have year round allergies?
Do you have a metallic taste in your mouth?
Do you have many food sensitivities?
     
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