DIRECTIONS
This questionnaire asks you to assess how you have been feeling during the last four months. This information will help you keep track of
how your physical, mental and emotional states respond to changes you make in your eating habits, priorities, supplement program, social and
family life, level of physical activity and time spent on personal growth. All information is held in strict confidence. Take all the time you need to
complete this questionnaire.
For each question in the following sections, select the answer that best describes your symptoms:
No or Rarely — You have never experienced the symptom or the symptom is familiar to you but you perceive it as insignificant (monthly or
less
Occasionally — Symptom comes and goes and is linked in your mind to stress, diet, fatigue or some identifiable trigger
Often — Symptom occurs 2-3 times per week and/or with a frequency that bothers you enough that you would like to do something about it
Frequently — Symptom occurs 4 or more times per week and/or you are aware of the symptom every day, or it occurs with regularity on a
monthly or cyclical basis