1. Hormone Balance - Please Check all that apply....

Symptoms of Hypothalamus Imbalance
Appetite disturbances	Memory problems
Thirst	Sensitivity to odors
Headaches	Constipation
Hot and Cold flashes	Diarrhea
Cold extremities	Descreased Libido
Extreme rage
Symptoms of Posterior Pituitary Imbalance
Fluid retention	Headaches
Excessive urination	Blood pressure imbalance
Bloating	Circulatory problems
Thirst	Bowel Gas
Symptoms of Anterior Pituitary Imbalance
Fatigue	Chronic headaches
Reduced Metabolic Rate	Skin pigment problems
Impotency	Water retention
Constipation	Seizure disorders
Diarrhea	TMJ
Symptoms of Thyroid Imbalance
Fatigue	Psychiatric disturbances
Depression	Constipation
Weight problems	Anxiousness
Dry or oily skin	Irritablility
Hair loss	Heat palpitation
Memory problems	Excessive energy
Mental sluggishness	Protruding eyes
Symptoms of Adrenal Imbalance
Fatigue	Stress
Hypertension	Inflammation
Allergies	Weight problems
Blood sugar swings	Frequent infections
Water retention	Abdominal weight gain
Kidney problems

II. Blood Sugar Balance - Yes or No

Do you feel tired after eating?
Do you feel fatigued mid morning or afternoon?
Do you ever feel light headed?
Do you ever see sports before your eyes?
Do you get cranky if you do not eat in time?

If you eat at the times below, what are the typical foods eaten?

Breakfast	________________________________________________________________
Snack	________________________________________________________________
Lunch	________________________________________________________________
Snack	________________________________________________________________
Dinner	________________________________________________________________
Bedtime	________________________________________________________________

III. Digestion - Upper and Lower GI

Belching	Constipation
Halitosis	Diarrhea
Heartburn	Hemorrhoids
Pain under right rib cage	Blood in stool
Gas	Stools float
Cramping	Stools lack bulk
Bloating

IV. Dietary Selection - Check what you do eat of the following...

White bread	Meat	Processed foods
Pasta	Poultry	TV dinners
Whole grains	Fish	Fast food
White rice	Salads	Organic food
Whole grain rice	Vegetables	Candy
Fruit	Nuts	Cookies
Fruit juices	Cereal	Ice cream
Pop	Beans	Milk
Coffee	Tofu or Soy	Cheese

Please answer the following questions...

Do you know what essential fatty acids are?__________________________________________
Do you supplement with flax, borage, EPA or other non-saturate oils?_____________________
Do you feel fatigued, depressed, bloating, gas or sinus changes when you eat?	_____________
How many times do you eat a day on the average?_____________________________________
Are your meals small _______    Medium  ________  Large _________ ?
Do you know about proper food combining?___________________________________________

V. Exercise Habits

How often do you exercise, and what is your routine? __________________________________

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VI. Emotional Health

Often, people's problem with weight loss can be related to their emotional well-being. If we are sad, depressed, afraid, overly protective, insecure of not feeling present in the moment, our bodies will respond with a slow metabolism, not letting go of the layers. This is an area not to be neglected, and if you feel there are some issues in this area for you, addressing them through therapy can make a significant difference. Feel free to make comments on this subject.

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Name ________________________________   Age _______  Height _______  Weight _______

Phone ________________________  Work ________________   Cell _____________________

Address _______________________________________________________________________

Email _________________________________________________________________________