Self-Assessment

Your email address:

Your name:

1. On average, do you consume more than 5 alcoholic beverages per week?

True

False

Question 1 of 37

2. Do you experience any of the following? (check all that apply)

Dry Eyes

Acid Reflux/Heartburn

Flushing (Redness NOT associated with rosacea)

“Brain Fog”

Constipation

Chronic pain and/or inflammation

None of these

Question 2 of 37

3. Do you experience any of the following? (check all that apply)

Bipolar (or Mania)

Depression

ADD/ADHD

OCD

Autism Spectrum Disorder

None of the above

Question 3 of 37

4. Do you experience symptoms associated with any of the following? (check all that apply)

Allergies (Seasonal)

Chronic Inflammation

Asthma

Hypothyroidism (Underactive Thyroid)

None of these

Question 4 of 37

5. Do you experience symptoms associated with any of the following? (check all that apply)

Headaches/Migraines

IBS, Constipation, and/or Diarrhea

Insomnia (hard time falling asleep or disturbed sleep)

None of these

Question 5 of 37

6. I get nervous or anxious when I have to learn something new at work or outside of the office.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 6 of 37

7. I crave fatty foods.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 7 of 37

8. I write things down so I won’t forget them.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 8 of 37

9. I have difficulty with doing math in my head (no calculator.)

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 9 of 37

10. I get sidetracked easily during a conversation, especially when interrupted.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 10 of 37

11. I lose my keys, wallet, or phone.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 11 of 37

12. I have episodes of low blood sugar where I am irritable (hangry), light-headed, and/or have cloudy thinking.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 12 of 37

13. I struggle with overall motivation and / or don’t have much interest in life activities / social interaction.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 13 of 37

14. I have a low libido or decreased levels of testosterone.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 14 of 37

15. I am a procrastinator.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 15 of 37

16. I struggle with addictions and/or have an “addictive personality”

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 16 of 37

17. I am sensitive to bright lights or loud noises, and sometimes get over-stimulated.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 17 of 37

18. I have cold hands or feet.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 18 of 37

19. I wake up multiple times during the night to use the bathroom.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 19 of 37

20. I have a hard time functioning in the morning without my coffee/tea.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 20 of 37

21. I tend to crave carbs (rather than sweets or junk food).

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 21 of 37

22. I struggle with a lack of focus while working or completing tasks.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 22 of 37

23. I start projects or tasks but have a hard time finishing them.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 23 of 37

24. I get night sweats and/or have clammy hands.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 24 of 37

25. I find myself getting irritable, impatient or edgy and/or I am snappy or emotional under stress.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 25 of 37

26. I tend to crave carbs or protein.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 26 of 37

27. I am a quick thinker but can have a hard time saying what I mean.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 27 of 37

28. I tend to expect the worst from people.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 28 of 37

29. I feel so stressed out or overwhelmed that it is difficult to think.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 29 of 37

30. I can be aggressive or have a hard time controlling my anger.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 30 of 37

31. I am a perfectionist or neat freak and tend to have obsessive thoughts and behaviors.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 31 of 37

32. I get the winter blues and often feel low in the winter time.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 32 of 37

33. I have trouble falling asleep and when I do, I often wake up and have trouble getting back to sleep.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 33 of 37

34. I get cravings for carbs and/or sweets, especially in the afternoon or evening.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 34 of 37

35. I sometimes find myself eating without realizing it, even when I’m not hungry.

Never/Almost Never

Rarely

Sometimes

Often

Most of the Time

Question 35 of 37

36. Ready to see your results?

Yes!

Question 36 of 37

37. Your Email Address:

Question 37 of 37

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