ToGetWell.com

Check off any statement that is a yes.

1. ENVIRONMENT

a. I live or work in a city or area that has smog or high traffic or factories and/or is considered a major city.

LIFESTYLE CHOICES

2. SMOKING

a. I do not smoke.

b. I do not smoke but I work or live where I am surrounded by smokers and I get second-hand smoke.

c. *I do smoke less than 5 cigarettes a day.

d. I do smoke between 5 to 15 cigarettes a day.

e. I do smoke between 16 to 30 cigarettes a day.

f. I do smoke more than a pack a day.

*Cigars: 1 medium Cigar is equal to smoking 3 cigarettes.

Pipes: 1 Pipe is equal to smoking 2 cigarettes.

3. DRINKING ALCOHOL *

a. I do not drink alcohol.

b. I drink 1 to 2 drinks a day.

c. I drink 2 to 5 drinks a day.

d. I drink 6 drinks or more a day.

* 1 drink is equal to 1 ounce of hard liquor or 1 bottle of beer or 1 glass of wine.

4. SEX

a. I feel that when it comes to sex I am physically below average.

b. I feel my sex drive is not what it used to be.

FOOD INTAKE AND FOOD PROCESSING

5. MEALS

a. I eat 1 meal a day.

b. I eat 2 meals a day.

c. I eat 3 meals a day.

d. I eat more than 3 meals a day.

e. I do not eat regular meals but I snack or eat small meals throughout the day.

f. I don’t eat much because usually I’m not hungry.

g. . I don’t eat much because I feel I’m losing my sense of taste and/or smell.

6. FRESH FRUIT AND FRESH VEGETABLES

(No frozen or canned)

a. I never eat fresh fruit and vegetables.

b. I eat one serving of fresh fruits and vegetables 2 times a week.

c. I eat 1 to 3 servings a day of fresh fruits and vegetables 3 times a week.

d. 1 eat 1 to 3 servings of fresh fruits and vegetables every day.

e. I eat 5 servings of fresh fruits and vegetables every day.

7. PROTEIN

(Beef, Chicken, Lamb, or Pork)

a. I eat protein 1 day a week.

b. I eat protein 2 days a week.

c. I eat protein 3 days a week.

d. I eat protein 4 days a week.

e. I eat protein 5 days a week.

f. I eat protein once a day, every day.

8. PROCESSED FOODS

(White bread, white flour, white rice, white sugars –all deserts and all sweets containing sugar, and sodas)

a. I eat processed foods less than 1 time a week.

b. I eat processed foods 1 to 2 times a week.

c. I eat processed foods once a day.

d. I eat processed foods 2 to 3 times a day, every day.

9. FATS

(Saturated fats found in meat, fried hamburgers, bacon, sausages,cold cuts, and dairy products, such as whole milk, cheese and butter)

a. I do not eat saturated fats or I’ll eat it once in a while ( not often).

b. I eat what I consider to be an average amount of meat, cheese and/or butter.

c. I love to eat fried foods such as fried hamburgers, bacon,and/or fried eggs.

d. I love to eat cold cuts or sausages.

e. I eat fatty foods at least once a day.

f. I eat dairy products at least once a day.

10 . MEATS

(Either smoked or with added preservatives which includes Bar–B-Q, smoked meats, canned meats, and cold cuts)

a. I eat this type of food 1 time a week or less.

b. I eat this type of food 2 to 4 times a week.

c. I eat this type of food 5 or more times a week.

d. I eat this type of food every day.

11. CANNED FOOD OR FREEZE DRIED FOODS

(Either alone or mixed with fresh or frozen food)

a. I eat canned food or freeze dried food once a week or less.

b. I eat canned food or freeze dried food 2 to 4 times a week.

c. I eat canned food or freeze dried food 4 times a week or more.

12. SALT AND SEASONINGS

a. I do not use any salt on my food.

b. I like salty foods so I sprinkle salt on my food, even before I taste my food.

c. I use Sea Salt on my food.

d. I prefer foods that are highly seasoned.

13. CAFFEINE

a. I drink more than 5 cups a day of drinks with caffeine (coffee, cocoa, tea, soft drinks)

14. MISSED MEALS

a. Sometimes I don’t have time to eat a breakfast or a lunch or a dinner because my work schedule or social/family schedule, so I eat fast foods or junk foods or I hit the vending machine instead so that I can keep on going.

b. If I miss a meal I don’t feel any different.

c. If I miss a meal I feel tired or weak or I slow down.

d. If I miss a meal I feel dizzy or nausea or I start shaking.

e. If I miss a meal I get irritable or have anxiety or I get short tempered.

PHYSICAL FITNESS

15. EXERCISE

a. I do not exercise.

b. I exercise 1 day a week.

c. I exercise under 30 minutes, 1 to 3 times a week.

d. I exercise more than 30 minutes 4 to 7 times a week.

e. I get muscle weakness even though I exercise.

16. WEIGHT

a. I am at the correct weight for my height.

b. I weigh 120 lbs. or less.

c. I weigh 121 lbs. to 180 lbs.

d. I weigh over 180 lbs.

e. I am 10 to 20 lbs. overweight.

f. I am 21 to 40 lbs. overweight

g. I am more than 40 lbs. Overweight

17. DIURETICS

a. I take medical diuretics daily.

b. I take natural diuretics daily.

18. BOWEL MOVEMENTS

a. I have a bowel movement once a week or less.

b. I have a bowel movement less than 3 times a week.

c. I have a bowel movement every other day.

d. I have 1 bowel movement a day.

e. I have 2 bowel movements a day.

f. I have 3 bowel movements a day.

g. I have more than 3 bowel movements a day.

h. I get recurrent constipation.

i. I get recurrent diarrhea.

j. I get intestinal upsets and/or bloated stomach after I eat.

19. DIGESTION

a. I get indigestion whenever I eat a meal.

b. When I get indigestion, I also get a sore mouth and a red tongue.

20. CHOLESTEROL

a. My cholesterol is over 200 mg/dl.

21. TRIGLYCERIDES

a. My triglycerides are over 300 mg/dl.

22. BLOOD PRESSURE

a. My last blood pressure reading was between : 90-120/ 60-80

b. 121-125/ 75-80

c. 126-139/ 75-89

d. over 139/ 89

23. HEART PALPITATIONS

a. I get recurrent palpitations.

24. BREATHING

a. Sometimes I find it hard to catch my breath.

b. Sometimes I have shortness of breath.

c. Sometimes I have a feeling of “tightness” in my chest.

MEDICATIONS

25. ASPIRIN

a. I never take aspirin.

b. I take an aspirin once in a while, maybe once or twice a year.

c. I take aspirin, or other items that contain aspirin, more than 2 times a week.

d. I take an aspirin every day.

26. ANTIHISTAMINES

a. I never take antihistamines.

b. I take antihistamines on an “as needed” basis, maybe once or twice a year.

c. I take antihistamines often. I feel like I am always taking antihistamines.

27. ALLERGIES

a. I have allergies caused by air-borne allergens such as pollen or dust.

b. I have allergies caused by pets such as pet dander, fur, or feathers.

c. I have food allergies but I’m not sure which foods cause me to have an allergic reaction.

28. COLD / FLU / SINUS

a. I often get colds

b. I often get the flu.

c. I often get sinus infections.

29. HEADACHES

a. I seldom get a headache.

b. I get headaches often.

c. I get migraine headaches.

30. BALANCE

a. I have head tremors (uncontrolled shaking).

b. I have good balance.

c. Sometimes I have loss of balance.

31. MEMORY

a. I am starting to forget things.

b. I definitely have a problem with remembering.

c. My memory used to be much sharper.

32. EYES

a. I often get burning eyes or a feeling of inflamed eyes under my eyelids.

b. I often get a sandy feeling under my eyelids.

c. I have difficulty seeing at night or in darkness.

d. I get blurred vision.

e. I get red, scaly patches on my eyelids.

f. My eyes are sensitive to bright light.

33. EARS

a. I get ringing in my ears(s).

b. I get a buzzing in my ear(s).

c. I get red, scaly patches on my ear(s).

34. HAIR

a. My hair is in poor condition. I’ve tried all kinds of hair products but nothing seems to improve my hair.

b. I have premature gray hair.

c. My hair is falling out.

d. I get greasy dandruff.

35. HAIR TESTS

I had a hair sample test done and it showed I had:

a. lead

b. mercury

c. aluminum

d. cadmium

e. arsenic

f. copper

36. FINGERNAILS

a. I have weak fingernails.

b. I have brittle fingernails

c. I have nails that chip or break between layers.

d. I have white spots or white stripes on the pink areas of my fingernails.

37. HANDS

a. Sometimes I have hand tremors (uncontrolled shaking).

b. I have brown spots on my hands (sometimes called “age spots”).

c. I have enlarged Middle joints on my fingers.

d. I often get cold hands.

e. I cannot touch my fingertips to the palm of my hand.

f. Testing one hand at a time, I can touch my fingertips to my palm but I feel a stiffness or pain.

g. Testing one hand at a time, I can touch my fingertips to my palm but there is no problem felt whatsoever.

38. SKIN

a. I get grayish, dry scaly skin flakes on my face.

b. I have very dry skin.

c. I am not able to suntan.

d. I have acne.

e. I have eczema.

f. I have psoriasis.

g. I get flaky skin on my forehead and sometimes around my nose and/or mouth.

h. I feel the cold more than everyone else does.

39. MOUTH AND TONGUE

a. I get cracked lips.

b. The corners of my mouth get red and scaly patches.

c. My mouth is sensitive to hot or cold liquids.

d. The tip of my tongue is a cherry red color.

e. I get cancer sores in my mouth.

f. I get cold sores (herpes simplex) on my lips.

g. I have an active herpes infection.

40. FEET

a. I get a feeling of burning feet.

b. I have a bone spur.

41. ANGER / NERVES / DEPRESSION

a. I get irritable easily.

b. I get nervous easily.

c. I lose my temper easily.

d. I get depressed easily and/or often but I get over it after a couple of days.

e. I don’t get depressed often but when I do it lasts

2 weeks or more.

42. ACHES AND PAINS

a. I often get fatigued.

b. I get aches and pains in my joints.

c. I get aches and pains in my back.

d. I get aches and pains in my neck.

e. I get aches and pains when I first get up in the morning but then,once I’m up, I feel okay.

f. I get leg cramps at night.

g. My leg muscles jump (or restless legs) at night.

h. I get sore muscles.

i. I get tender muscles.

43. BEHAVIORAL

a. I have a lot of stress at home and at work.

b. I have trouble sleeping at night.

44. WOMEN ONLY

a. I get premenstrual cramps.

b. I get premenstrual nervousness.

c. I do take birth control pills.

d. I do not take birth control pills.

e. I am post-menopausal and I am on hormone replacement therapy (HRT).

f. I am post-menopausal and I am not on hormone replacement therapy (HRT).

Reprinted from ToGetWell.com

Copyright 2004: Ruth M. Rojo, ND, PhD