Blood Sugar Instability Questionnaire

Instructions

Fill in the answers by selecting either "Yes" or "No"
Submit the questionnaire by hitting the "Submit" button

Name

First Name

Last Name

Email Address

Home Zip Code

Work Zip Code

Today's Date

YYYY

Family history of diabetes or hypoglycemia or alcoholism

Calmer after meals

Frequent thirst

Night sweats

Not caused by menopause

Crave salty foods

Dark circles under eyes or eyes sensitive to bright light

More awake at night

Food cravings

Headaches

Irritability

Mood swings

Easily fatigued

Anxiety

Difficulty sleeping

Mental sluggishness

Eat when nervous

Excessive appetite for carbohydrates or sweets

Hungry between meals

Irritable before meals

Shaky if hungry

Lightheaded if skip meals

Low energy in afternoon

Afternoon headaches

Crave sweets or coffee in afternoon

Dr. Kwik's Body Intelligent Center

Dr. Paul is a Chiropractor and has enjoyed an active practice in Orange County, California since 1993 and he is grateful to have helped many people throughout Orange and Los Angeles counties obtain the relief and health they desire. He has a family practice ranging from newborns to the elderly; treating a variety of symptoms ranging from runny noses, digestive disturbances and endocrine imbalances as well as migraine headaches, neck/low back and extremity pain.

Dr Kwik specializes in Gentle, Non force Chiropractic care (Active Release Technique and Acupressure for Pain and Stress Reduction) and Specific Bio Electric Reflex testing (Nutritional Reflex Assessment) to analyze the body’s nutritional and structural imbalances so that the root cause of a problem can be identified. Many come to Dr. Paul after treatments with other practitioners have failed.