Name *

First Name

Last Name

COGNITION *

Do You have Memory Issues? Difficulty remembering recent events Trouble concentrating or processing information Repeatedly losing items or forgetting tasks

Yes

No

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Do You have: Anxiety Persistent feelings of worry or nervousness Physical tension or restlessness Difficulty sleeping due to overthinking

Yes

No

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Do You have: Extreme mood swings from high energy (mania) to deep sadness (depression) Difficulty managing emotions Impulsive or risky behavior during manic episodes

Yes

No

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Do You have: Social Communication Challenges Difficulty understanding social cues Preference for routines and difficulty with change Sensory sensitivities (e.g., light, sound, texture)

Yes

No

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Do You have: Mental Focus Issues Struggling to maintain attention Procrastination or disorganization Difficulty completing tasks

Yes

No

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Do You have: Cardiovascular Disease Shortness of breath during mild activity Chest pain or discomfort Swelling in legs or fatigue

Yes

No

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Do You have: Chronic Fatigue Feeling tired despite adequate rest Difficulty staying awake or alert Weakness or low stamina

Yes

No

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Do You have: Depression Persistent sadness or lack of interest Feelings of hopelessness Low energy or motivation

Yes

No

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Do You have: Exercise Intolerance Unusual fatigue after physical activity Difficulty recovering from workouts Avoidance of exercise due to discomfort

Yes

No

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Do You have: Headaches and Migraines Frequent or severe headaches Sensitivity to light or sound during headaches Nausea or vision changes with migraines

Yes

No

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Do You have: High Blood Pressure Frequent dizziness or headaches Flushed face or chest tightness Shortness of breath during rest or exertion

Yes

No

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Do You have: ADD/ADHD Easily distracted or restless Struggling to complete tasks Difficulty staying organized

Yes

No

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Do You have: Insomnia Difficulty falling or staying asleep Waking up feeling unrefreshed Fatigue due to poor sleep

Yes

No

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Do You have: Insulin Resistance or Diabetes Increased thirst or frequent urination Fatigue after eating sugary foods Difficulty managing blood sugar levels

Yes

No

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Do You have: Hypoglycemia Feeling shaky or lightheaded when hungry Sudden drops in energy Cravings for sugary foods

Yes

No

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Do You have: Liver Disease or Poor Detoxification Jaundice (yellowing of skin or eyes) Nausea or bloating after meals Dark urine or pale stools

Yes

No

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Do You have: Nutritional Insufficiencies Frequent cravings for specific foods Poor hair, skin, or nail health Fatigue or low immunity

Yes

No

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Do You have: Parkinson's or Motor Issues Shaking or tremors Slowness of movement Muscle stiffness or rigidity

Yes

No

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Do You have: Poor Muscle Mass Weakness or difficulty gaining strength Decreased stamina Muscle wasting or lack of tone

Yes

No

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Do You have: Thought Disorders Difficulty distinguishing reality from delusions Hallucinations (seeing or hearing things that aren’t there) Disorganized thinking or behavior

Yes

No

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Do You have: Skin Conditions Persistent rashes, dryness, or irritation Acne, eczema, or psoriasis Slow healing of wounds

Yes

No

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Do You have: Toxicity or Detox Challenges Sensitivity to chemicals or strong smells Persistent fatigue or brain fog Difficulty losing weight despite effort

Yes

No

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Do You have: Unexplained Chronic Illness Persistent symptoms without diagnosis Fatigue, pain, or discomfort Difficulty maintaining daily activities

Yes

No

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Do You have: Weight Loss Resistance Struggling to lose weight despite diet/exercise Frequent plateaus in weight loss efforts Low energy or cravings

Yes

No

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Do You have: Weight Loss Resistance Struggling to lose weight despite diet/exercise Frequent plateaus in weight loss efforts Low energy or cravings

Yes

No