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Your Information
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Mood Assessment
In the past 3 months, how often have you...
Found it hard to feel wide awake within 30 minutes after rising?
Needed a stimulant like coffee, tea, something sweet, or a cigarette to help wake you up in the morning?
Felt tired or sluggish after eating a meal or during the day?
Craved something sweet or a stimulant after eating a meal?
Felt irritable or faint if going 6 ours without eating something?
Had a hard time concentrating or experienced mood swings?
Craved sweet foods, dessert, chocolate, bread, cookies, cereal or pasta?
Had added sugars in your drinks (or added sugar yourself), in your drinks, or had sauces, gravy., or other foods with hidden sugars?
Consumed certain foods to prevent anxiety, help you relax, or help you cope with stressful situations?
Felt depressed, exhausted, or too tired to move your body or do physical activity?
Gastrointestinal Assessment
Taken antacid or acid reflux tablets?
Felt indigestion or a burning sensation in your stomach?
Felt stomach discomfort or an uncomfortable feeling of fullness even 5 hours after eating?
Felt pain or difficulty digesting fatty or oily foods.
Felt a bloated stomach or pain from eating certain foods.
Suffered from constipation?
Suffered from diarrhea?
Felt nauseated after eating or suffered from vomiting.
Burped, hiccuped, or passed gas persistently?
Failed to have a bowel movement at least once a day?
Toxicity Assessment
Had sinus issues, a runny or stuffy nose, or excessive mucus?
Had acne, skin spots, cold sores, athlete’s foot, rashes, or hives?
Had blocked or itchy ears, pain or ringing in your ears, ear infections, or ear discharge?
Had watery or itchy eyes, swollen, red, or sticky eyelids, or dark circles or bags under your eyes?
Had an unpleasant or bitter taste in your mouth?
Suffered from bad breath?
Suffered from a foul body odor, including your arm pits or your feet?
Not been able to tolerate coffee or caffeine or felt unwell after having coffee or caffeine?
Not been able to tolerate a small amount of alcohol or felt hungover the next day after consuming alcohol?
Found it hard to lose weight or suffered from a sluggish metabolism?
Inflammation Assessment
Taken painkillers or anti-inflammatory medications?
Suffered from allergic reactions or hay fever?
Had pains or aches in your joints or muscles?
Suffered from bloating or water retention?
Suffered from irritable bowel syndrome (IBS)?
Suffered from dermatitis, eczema, rashes, or itches?
Suffered from shortness of breath or asthma?
Suffered from colitis (colon inflammation), Crohn’s Disease, or diverticulitis?
Suffered from headaches or migraines?
Suffered from any other aches, pains, infections, or inflammation symptoms?
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