1) Do you experience problems falling asleep? Yes:
2) Do you experience problems staying asleep? Yes:
3) What time do you normally go to bed?
4) What time do you normally awaken?
5) Do you feel rested upon awakening? Yes:
6) Do you awaken regularly between 2-3am? Yes:
7) Do you recall your dreams? Yes:
8) Do you frequently have nightmares? Yes:
9) Is your energy good all day? Yes:
If no, what time of day is your energy best?
What time is the lowest?
10) Do you feel tired all the time? Yes:
11) Do you suffer from depression? Yes:
If yes, please describe:
12) Do you suffer from pain? Yes:
If yes, please explain:
13) Are you mentally and emotionally exceptionally stressed? Yes:
If yes, how long have you felt this way?
14) Do you suffer from low blood sugar? Yes:
If yes, please explain:
15) How many meals (including snacks) do you eat a day?
16) How much time between meals/snacks?
17) Do you eat within 1 hour of awakening? Yes:
If yes, please describe a typical breakfast:
If no, how long after awakening until you eat your first meal of the day?
18) describe that typical meal:
19) Do you have a bedtime smack? Yes:
If yes, please describe:
20) Please describe a typical day's meals and snacks from awakening until bedtime (ending your day).
Breakfast: Time:
Lunch: Time:
Dinner/Supper: Time:
Snack: Time:
21) Do you frequently skip meals? Yes:
22) Do you need caffeine (coffee, tea, etc.) to get you going in the morning? Yes:
23) Do loud noises (sounds) bother you? Yes:
24) Are you startled easily? Yes:
25) Do you suffer from allergies? Yes:
26) Do you suffer from recurrent/chronic infections? Yes:
27) Do you take thyroid hormones? Yes:
If yes, please list type, dosage, and how long you have been taking thyroid hormones:
28) Are you taking any other hormones? Yes:
If yes, please list type, dosage, and how long you have been taking them:
29) Do you suffer from mental confusion? Yes:
30) Do you suffer from chronic headaches? Yes:
31) Do you experience light-headedness? Yes:
32) Have you ever fainted? Yes:
33) Are you easily upset? Yes:
34) Are you taking any sleeping medication? Yes:
If yes, please list:
35) Are you taking any anti-depressants? Yes:
If yes, please list type and dosage:
If yes, how long have you been taking them:
36) Do you exercise? Yes:
If yes, what type, time of day, how long, how often:
If no, is there any reason you cannot exercise? Yes:
If yes, please explain:
37) Do you feel better or worse after exercise? Better:
38) Do you frequently experience a second wind (high energy) late at night? Yes:
39) What is your daytime light source? (i.e. indoor/outdoor, fluorescent, full spectrum, etc.)
40) How much time do you get outdoor light (direct or indirect) daily?
41) Do you wear sunglasses when you are outdoors? Yes:
42) Does sunlight bother your eyes? Yes:
43) Do you have high blood pressure? Yes:
If yes, are you taking any medication? Yes:
If yes, please list type and dosage?
44) Do you have low blood pressure? Yes:
45) Do you feel nauseous? Yes:
46) Do you have bloating? Yes:
47) Do you get heartburn? Yes:
48) Do you have constipation? Yes:
49) Do you have gas? Yes:
50) Do you belch following meals? Yes:
51) Do your bowel movements alternate between constipation and diarrhea? Yes:
52) Do you have abdominal/intestinal pain? Yes:
53) Do you get bloated after meals? Yes:
54) Do you have diarrhea? Yes:
55) Do you travel outside of the U.S.? Yes:
56) Are your stools compact/hard to pass? Yes:
57) Do you have gurgles in your stomach? Yes:
58) Do you have any known food allergies? Yes:
59) What is your heritage? (i.e. Irish, German, etc)
60) Have you had any root canals? Yes:
If yes, how many and when:
61) Have you had any teeth extracted, including wisdom teeth? Yes:
If yes, when:
62) Do you have a dental bridge in your mouth? Yes:
If yes, what is the material:
63) Do you have fillings? Yes:
If yes, how many and what materials were used:
64) Do you have braces? Yes:
65) Do you use a dental splint? Yes:
If yes, what is the material used:
66) Do you have TMJ (jaw problems)? Yes:
If yes, please describe:
67) Describe any believed exposure(s) to environmental and/or chemical toxins:
68) Describe your hobbies and form of recreation:
69) Are you currently taking nutritional supplements? Yes:
If yes, please list all products and daily dosages:
70) Have you ever had any head, neck, or back injuries? Yes:
If yes, please describe:
71) How long has it been since you have felt your best?
