Stop for a moment and tune into how you have felt during the past month.

Then respond to each question on a scale from 0 (for never) to 5 (for frequently). Postmenopausal women should answer any applicable questions based on their previous menstrual history.

Name *
Name
Feeling depressed or negative
Feeling that work, relationships, and hobbies have lost significance
Feeling physically and/or mentally worse in winter
Feeling abnormally weak or fatigued
Dry or itchy skin on face or hands
Skin redness or flushing
Loss of and/or slow-growing hair
Slow-growing or brittle nails
Bruise easily
Difficulty losing weight
Cold hands and feet
Low body temperature; often feel colder than those around you
Constipation (bowels don’t move daily) or difficult bowel movements
Feeling stressed, overwhelmed, burned out
Experience frequent or intense mood swings
Loss of motivation or initiative to start new projects, participate in hobbies
Feeling anxious, jittery, nervous
Frequently wake feeling tired or unrested
Fatigue or loss of energy, particularly in the late afternoon and evening
Feel drained or fatigued by exercise
Tend to 'bonk' during extended/endurance activity
Difficulty recovering from physical exercise
Decrease in athletic performance or making progress in training
Decrease in physical stamina or endurance
Loss of agility, reduced quickness
Frequent back or neck pain
Difficulty gaining weight
Cravings for caffeine, sugar, and/or chocolate
Decrease or less than optimal muscle size, tone, and strength
Low blood pressure
Obsessive-compulsive behaviors; perfectionistic tendencies
Spells of mental fatigue, inability to concentrate
Feeling irritable, angry, or hostile
Decreased mental sharpness, wit, attention
Change in mental function; poor memory or increased forgetfulness
Diminished verbal recall
Difficulty falling asleep and/or sleeping through the night
Vivid recall of dreams
Cravings for fatty, oily, or salty foods
History of binge or compulsive eating and/or heavy drinking
Racing thoughts; unable to quiet the mind
Joint pain, swelling (worse in the morning), arthritis
Stiffness or limited movement
Acne as teen or adult
Hives or rashes
Susceptible to infections (skin, sinus, bladder, vaginal, etc.)
Susceptible to colds or flu
Food or seasonal allergies
Bags or dark circles under the eyes
Blurred vision
Itchy ears, ear aches, or ear infections
Ringing in ears, hearing loss
Sinus problems; stuffy or bloody nose
Frequent gagging or need to clear throat
Sore throat, hoarseness, loss of voice
Headaches or migraines
Chronic cough and/or chest congestion
Shortness of breath with activities
Frequent or urgent urination
History of autoimmune disease
Lightheadedness, dizzy spells, ringing in the ears
Feeling sore all over; aches in joints and muscles
Frequent injuries or delayed recovery
Recurring and/or repetitive overuse injuries
Decrease in flexibility and mobility
Increased tendency toward muscle pulls or leg cramping
Cravings for ice chips or cubes
Poor circulation in legs, swollen ankles, varicose veins, or hemorrhoids
Numbness in the hands and/or feet
Dulling or loss of senses such as vision, taste, or smell
History of bone fractures; weak or thinning bones
Menstrual cramping, excessive bleeding, or other irregularities
Excessive sweating during the day or at night
Breast tenderness, lumpiness, enlargement, fibrocystic breasts
Hot flashes or excessive sweating
Premenstrual anxiety, hostility, or mood swings
Difficulty becoming pregnant; history of miscarriages
Take or have taken birth control pills for extended periods of time
High total cholesterol or triglycerides and/or low HDL cholesterol
High blood sugar or insulin
High blood pressure
Unexplained weight gain, particularly in the midsection
Water retention; bloating and/or swelling (face, hands, legs, ankles, feet)
Always hungry
Cravings for starchy carbohydrates like breads, cereals, pasta, etc.
Difficulty digesting protein and fats
Indigestion or acid reflux; slow or difficult digestion
Gas, belching, or bloating after eating
Upset stomach, burping, acid reflux
Prone to nausea or vomiting
Loose stools or diarrhea
Celiac disease, IBS, or gluten sensitivity

That’s it. And now that your Symptom Survey is complete, you’ll have the opportunity to find out what all these numbers mean! Once you click the SUBMIT button, you’ll be redirected to an appointment calendar so that we can schedule some time to talk. We’ll need about 10 minutes together to discuss your results and your goals—with no cost or obligation involved.