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Fill Out My Custom Questionaire 🙂

Answer all questions as honestly as possible, and I will review!

The Questionaire
Name
Name
First
Last
Do you experience excessive belching, burping and/or bloating?
Do suffer from gas immediately following a meal?
Do you ever have difficult bowel movements?
Do you have an uncomfortable sense of fullness during meals ?
Do you have a history of anemia?
Are you a vegetarian who doesn’t eggs or dairy products?
Do you get sores in the corner of your mouth?
If you examine your tongue?
Do you have spoon-shaped nails ?
Do you suffer from a partial loss of taste or smell?
Do you suffer from indigestion and fullness lasting 2 to 4 hours after eating?
Do suffer from pain, tenderness and/or soreness on your left side under your rib cage?
Do you ever have an excessive passing of gas?
Do you feel constantly bloated?
Do specific foods or beverages aggravate your digestion?
Do you experience abdominal cramps or stomach aches?
Do you frequently experience nausea and/or vomitting?
Do you have alternating constipation and diarrhea?
Do you have undigested food in your stool?
Do you have signs of mucus in your stool?
Do you have difficulty gaining weight?
Do you suffer stomach pains and/or burning, aching 1 to 4 hours after eating?
Do you get heartburn from spicy foods when you are lying down or bending forward?
Do you have difficulty or pain when swallowing?
Do you experience relief from carbonated beverages, cream, milk or food ?
Do you have black tarry-looking stools?
Do you suffer from lower abdominal pain, cramping and/or spasms?
Do you find relief from lower abdominal pain by passing stools or gas?
Do you experience more than three bowel movements within a day?
Do you suffer from painful, difficult, straining during bowel movements?
Do you produce hard, dry or small stools?
Do you feel that your bowels do not empty completely?
Do you suffer from anal itching?
Do you regurgitate bitter fluid?
Do you find that fatty foods cause indigestion?
Do you suffer from unexplained itchy skin which is worse at night?
Does your stool color alternate between clay colored and normal brown?
Do you suffer from fatigue, weakness and/or exhaustion?
Do you ever feel unable to concentrate, feel irritable and/or confused ?
Do you suffer from swollen feet and/or legs?
Do you find your skin is easily bruised?
Do you suffer from dry, flaky skin and hair?
Do you have a yellowish cast to your skin and around your eyes?
Are the outer third of your eyebrows thin?
Do you have dark urine and/or a diminished flow?
Do you have swollen upper eyelids?
Do you suffer from slow mental processes and forgetfulness?
Do you suffer from slow heart beats?
Do you have a lack of interest in sex?
Do you suffer from premenstrual tension?
Do you suffer from heavy menstrual bleeding?
Do you suffer from infertility?
Do you gain weight easily?
Do you suffer from thinning hair on your scalp, face and genitals?
Do you suffer from general weakness?
Do you suffer from progressive, mild fatigue after exertion or stress?
Do you suffer from depression?
Do you suffer from blurred vision and/or dizziness when rising?
Do you suffer from rapid mood swings?
Do you feel irritable and/or nervous?
Do you have dark circles under your eyes?
Do you have blotchy skin which includes white patches?
Do you suffer from spinal curvature?
Have you suffered a recent loss of height?
Do you suffer from unexplained bone fractures?
Do you suffer from tooth loss and/or gum disease?
Are there specific points on your body that feel sore when pressed?
Do you suffer excessive looseness of joints?
Do you suffer from numbing and tingling sensations?
Are you double jointed?
Do you feel fatigued and sluggish?
Do you have difficult and/or infrequent bowel movements?
Do your muscles feel weak, do they cramp and/or tremble?
Do you suffer from loss of appetite?
Do you suffer from an unsteady gait and abnormal walking movements?
Do you feel disinterested in food?
Do you suffer from indigestion?
Do you have a craving for salty foods?
Do you suffer from generalized bone tenderness and aching?
Do your shins hurt during or after exercises?
Do you suffer from hearing loss, headaches, and/or ringing in the ears?
Do you suffer joint pain and stiffness – especially in your spine, hips and/or knees?
Do you suffer from localized muscle stiffness, tension and/or pain?
Do you suffer from headaches?
Do you have difficulty sleeping?
Do you suffer from muscle weakness or loss?
Do you feel un-refreshed upon awakening?
Do your muscles twitch or tremble, such as your eyelids, calf muscles, or your thumb?
Do you have an irresistible urge to move your legs?
Do you suffer from joint stiffness and/or soreness?
Do your legs move during your sleep?
Does your joint stiffness worsen with rest and improve with movement?
Do you have a limited range of motion?
Do you have difficulty standing up from a sitting position?
Do you suffer numbness, prickling and/or a tingling sensation in the neck, shoulder and/or arms?
Any Exposure? Radio Tower?
Any exposure? Landfill dump?
Exposure at Home or Work – water leaks ?
Exposure at Home or Work – visible mold ?
Exposure at Home or Work – damp basement ?
Exposure at Home or Work – carpets ?
Have you been exposed to secondary smoking ?
Do you smoke cigarettes / cigars / pipe ?
Have you come into contact (significantly) with pesticides, herbicides, chemicals, varnish, glue, paints, cleaning agents, mercury, lead ?
Do you have allergies?
Do you regularly consume artificial sweeteners ?
Are you subject to frequent airplane travel ?
Do you drink soda ?
Do you feel under stress ?
Do you regularly consume alcohol ?
Have you ever had food poisoning ?
Have you ever experienced a traumatic event ?
Dental work – Do you have amalgam fillings ?
Have you ever indulged in recreational drugs ?
Dental Work – Do you have any root canals ?
If I have nothing for breakfast or perhaps just some coffee, it’s easier to control my eating for the rest of the day, than if I have breakfast that contains carbohydrates.
I’m a “bet you can’t eat just one” person and find it difficult to stop once I start snacking on sweets and starches.
I often feel very sluggish and/or hungry by mid-afternoon.
Cakes, cookies and other sweets make me feel better if I am feeling “down” or tired.
If I am trying to diet and lose some weight, it’s easier to skip meals and not eat for most of the day, than to try to eat small diet meals.
A meal including bread or potatoes or pasta or dessert has often left me feeling sleepy, tired,or “drugged”. A meal made up of only meat and salad does not have the same effect.
Sometimes I would classify myself as a “secret eater”.
A meal of only meat and vegetables does not satisfy me.
I prefer potatoes, bread, pasta and dessert to other foods and will often skip eating salads and vegetables for them.
I often crave a bedtime snack before going to sleep.
If I wake in the middle of the night, it’s easier to get back to sleep if I snack something.
When at a restaurant, I often eat too much bread before the meal is served.
Watching other people eat when I am not is annoying to me.