Tell Us What You’re Experiencing

By completing this survey, you give our doctor the insight needed to understand your health story.

Then, you’ll schedule a free consultation call to discuss what you’ve been experiencing and your best path forward.

SURVEY

These questions provide clues to the causes of your health problems.

If you don’t have a symptom, leave the question blank.

Tell Us What You’re Experiencing

By completing this survey, you give our doctor the insight needed to understand your health story.

Then, you’ll schedule a free consultation call to discuss what you’ve been experiencing and your best path forward.

SURVEY

These questions provide clues to the causes of your health problems.

If you don’t have a symptom, leave the question blank.

Category 1: Female Sex Hormones
Sex hormones affect overall health: emotions, weight, skin/hair/nails as well as menstrual cycle, fertility and menopause.
Irregular periods
PMS
Hysterectomy
Infertility
Low or no libido
Hot flashes or night sweats
Skin: Acne, Breakouts
Depression of long standing
Thin, brittle hair or slow hair growth
Thin, brittle nails

Category 2: Liver/Digestion
Detoxification, fat metabolism and immune functions.
High cholesterol
High blood pressure
Blurred vision
Poor or excessive appetite
Heartburn, reflux
Gas, bloating
Constipation

Category 3: Adrenal
Stress handling, Blood sugar, Immune, Sex hormones and Fluid balance.
Stressed, can't handle stress, anxiety
Food or environmental allergies
Fatigue or exhaustion
Sleep problems, can't wake up in mornings
Crave sugar, carbs or junk foods
Trouble getting to sleep or wakes in night

Category 4: Heart/Cardiovascular
Circulation, energy levels.
Aware of "breathing heavily"
In anyway aware of the heart
Get "drowsy" often
Afternoon "yawner"
Noises in head, or "ringing in ears"
Shortness of breath on exertion

Just three more sections to go!
Category 5: Thyroid
Metabolic regulation, Heart rhythm, Brain function .
Heart palpitations
Stubborn weight
Sensitive to cold, cold hands & feet
Sleepy during day
Mental sluggishness, lethargy
Dry or scaly skin
Anxiety

Category 6: Blood Sugar
Blood sugar affects fatigue, sleep, cravings and irritability.
Get "shaky" or irritable if hungry
Eat when nervous
Moods of depression - "blues"
Afternoon craving of sweets, carbs, coffee
Tired in afternoons

Category 7: Allergies
Allergies affect digestive health, immune health and inflammation levels as well as concentration and memory.
Difficulty focusing
Picky eater or poor appetite
Skin rashes or hives
Memory problems
Joint pain

Almost Done!

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Overall, is this problem tending to:
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