Your Name (required)

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Once you complete the assessment, please press “Submit” button and the system will email it back to you as well as your healthcare practitioner.

0 = Never true, 1= Seldom true, 2= Sometimes true, 3= Often true

Section A
For the past two weeks or longer, I…
1 Get wound up when I get tired and have trouble calming down. 0123
2 Feel driven, appear energetic but feel “burned out” and exhausted.0123
3 Feel restless, agitated, anxious, and uneasy. 0123
4 Feel easily overwhelmed by emotion. 0123
5 Feel emotional — cry easily or laugh inappropriately 0123
6 Experience heart palpitations or a pounding in my chest. 0123
7 Am short of breath 0123
8 Am constipated. 0123
9 Feel warm, over-heated, and dry all over. 0123
10 Get mouth sores or sore tongue. 0123
11 Get hot flashes. 0123
12 Sleep less than seven hours a night 0123
13 Have trouble falling asleep and staying asleep. 0123
14 Worry about high blood pressure, cholesterol, and triglycerides. 0123
15 Forget to eat and feel little hunger 0123

Section B
1 Find myself worrying about things big and small 0123
2 Feel like I can’t stop worrying, even though I want to. 0123
3 Feel impulsive, pent up, and ready to explode. 0123
4 Get muscle spasms. 0123
5 Feel aggressive, unyielding, or inflexible when pressed for time. 0123
6 See, hear, and smell things that others do not. 0123
7 Stay awake replaying the events of the day or planning for tomorrow. 0123
8 Have upsetting thoughts or images enter my mind again and again 0123
9 Have a hard time stopping myself from doing things again and again, like checking on things or rearranging objects over and over 0123
10 Worry a lot about terrible things that could happen if I’m not careful. 0123

Section C
1 Have muscle and joint pains 0123
2 Have muscle weakness 0123
3 Crave salt or salty things 0123
4 Have multiple points on my body that when touched are tender or painful 0123
5 Have dark circles under my eyes 0123
6 Feel a sudden sense of anxiety when I get hungry 0123
7 Use medications to manage pain 0123
8 Get dizzy when rising or standing up from a kneeling or sitting position 0123
9 Have diarrhea or bouts of nausea with or without vomiting for no apparent reason 0123
10 Have headaches 0123

Section D
1 Have trouble organizing my thoughts. 0123
2 Get easily distracted and lose focus. 0123
3 Have difficulty making decisions and mistrust my judgment. 0123
4 Feel depressed and apathetic 0123
5 Lack the motivation and energy to stay on task and pay attention. 0123
6 Am forgetful 0123
7 Feel unsettled, restless, and anxious 0123
8 Wake up tired and un-refreshed 0123
9 Experience heartburn and indigestion 0123
10 Catch colds or infections easily 0123

Section E
1 Feel tired for no apparent reason 0123
2 Experience lingering mild fatigue after exertion or physical activity 0123
3 Find it difficult to concentrate and complete tasks 0123
4 Feel depressed and apathetic 0123
5 Feel cold or chilled – hands, feet, or all over – for no apparent reason 0123
6 Have little or no interest in sex. 0123
7 Sweat spontaneously during the day 0123
8 Feel puffy and retain fluids 0123
9 Sleep more than nine hours a night 0123
10 Have poor muscle tone 0123
11 Have trouble losing weight 0123
12 Wake up tired even though I seem to get plenty of sleep 0123
13 Have no energy and feel physically weak 0123
14 Am susceptible to colds and the flu 0123
15 Feel dragged down by multiple symptoms, such as poor digestion and body aches 0123

Lifestyle & Health Status:
1 Rate the level of stress you experience on the scale of 1-10, 10 being the worst: 12345678910

2 What do you consider to be the major causes of your stress (for example — spouse, family, friends, work, finances, wedding, pregnancy, legal, commute):

3 How many times per week do you eat breakfast? —Please choose an option—Daily5-6 times per week3-4 times per week1-2 times per weekLess than once per week

3a. What is your typical breakfast?

4 How many days per week do you take a vitamin/mineral? 1234567

4a. How many days per week do you take a fish oil supplement? 1234567

5 How often do you participate in at least 30 minutes of physical activity such as walking, aerobics (e.g., running), resistance training (e.g., weights, pilates), biking or yoga? —Please choose an option—Daily5-6 times per week3-4 times per week1-2 times per weekLess than once per week

6 If you smoke, how many cigarettes do you smoke daily. 012345678910

7 How often to you drink two or more 8 ounce cups of caffeinated coffee or other caffeinated beverages like energy/diet drinks, colas, or black or green teas: —Please choose an option—Daily5-6 times per week3-4 times per week1-2 times per weekLess than once per week

8 How often do you drink two or more ounces of alcoholic beverages? —Please choose an option—Daily5-6 times per week3-4 times per week1-2 times per weekLess than once per week

9 List your current health problems and any over-the-counter or prescription medications that you are now taking:

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