Wellness Survey Answer on a 0-3 scale. 0 = Never1 = Rarely2 = Weekly/Moderate3 = Daily, Frequently Name * First Name Last Name Email * Phone (###) ### #### High Blood Sugar • Crave Sweets/Carbs 0 1 2 3 High Blood Sugar • Crave Sweets after meals 0 1 2 3 High Blood Sugar • Frequent thirst 0 1 2 3 High Blood Sugar • Fatigue after meals 0 1 2 3 High Blood Sugar • Irritable or shaky relieved by food 0 1 2 3 Low Blood Sugar • Irritable or shaky relieved by food 0 1 2 3 Low Blood Sugar • Fatigue relieved by food 0 1 2 3 Low Blood Sugar • Feeling the need for caffeine (morning/afternoon) 0 1 2 3 Low Blood Sugar • Wake up often during sleep cycle 0 1 2 3 Low Cortisol • Dragging in the morning 0 1 2 3 Low Cortisol • Low Energy 0 1 2 3 Low Cortisol • Crave salt 0 1 2 3 Low Cortisol • Feeling of tired yet wired 0 1 2 3 Low Cortisol • Can’t shut down and relax 0 1 2 3 Low Cortisol • Fat around the belly 0 1 2 3 Small Intestine • Heartburn 0 1 2 3 Small Intestine • Intolerance to fried foods 0 1 2 3 Small Intestine • Upper right quadrant pain 0 1 2 3 Small Intestine • Food sensitivities 0 1 2 3 Small Intestine • Formula fed not breast fed as a baby 0 1 2 3 Large intestine • Constipation 0 1 2 3 Large intestine • Loose Stool 0 1 2 3 Large intestine • Frequent gas 0 1 2 3 Large intestine • Indigestion 0 1 2 3 Large intestine • History of antibiotic use 0 1 2 3 Liver/Gallbladder • Greasy stools that float 0 1 2 3 Liver/Gallbladder • Sensitivity to chemical smells 0 1 2 3 Liver/Gallbladder • Metabolize alcohol and RX drugs slowly ( very little needed for effective result) 0 1 2 3 Thyroid • Brain fog 0 1 2 3 Thyroid • Feeling like you can never fully wake up 0 1 2 3 Thyroid • Very dry skin 0 1 2 3 Thyroid • Tendency to cold hands and feet 0 1 2 3 Thyroid • Difficulty losing weight 0 1 2 3 Male Sex Hormones • Lost enjoyment of standard activities 0 1 2 3 Male Sex Hormones • Loss of muscle mass 0 1 2 3 Male Sex Hormones • Decreased libido 0 1 2 3 Male Sex Hormones • Decreased sexual stamina 0 1 2 3 Male Sex Hormones • Excessive soreness during and after exercise 0 1 2 3 Female Sex Hormones • Decreased libido 0 1 2 3 Female Sex Hormones • Acne 0 1 2 3 Female Sex Hormones • Unwanted facial hair 0 1 2 3 Female Sex Hormones • PMS 0 1 2 3 Female Sex Hormones • Hot flashes 0 1 2 3 Female Sex Hormones • Painful sex 0 1 2 3 Female Sex Hormones • Excessive soreness during and after 0 1 2 3 Female Sex Hormones • Decreased muscle mass 0 1 2 3 Nutrients • Bleeding gums 0 1 2 3 Nutrients • Bruising easily 0 1 2 3 Nutrients • Muscle cramping 0 1 2 3 Nutrients • Restless leg 0 1 2 3 Oxygenation/Hydration • Shortness of breath 0 1 2 3 Oxygenation/Hydration • Rapid heartbeat 0 1 2 3 Oxygenation/Hydration • Fatigue when walking up stairs 0 1 2 3 Oxygenation/Hydration • Frequent thirst 0 1 2 3 Oxygenation/Hydration • Frequent headaches 0 1 2 3 Oxygenation/Hydration • Poor circulation 0 1 2 3 Oxygenation/Hydration • Shallow breathing 0 1 2 3 Oxygenation/Hydration • Sleep apnea 0 1 2 3 Thank you! Thank you for participating! -Melissa and RussYou can purchase our best selling book here!Daily Practices- A Mindfulness Companion
