Rate the following symptoms that you experience on a scale of 0-3. Choose the number that best represents how true this question is for you. 0 - not true at all/ does not relate to you at all 1 - true to a small degree/having a small but noticeable impact on your daily life2 - true to a moderate degree/having a moderate impact on your daily3 - true to a large degree and significant
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Question 1 of 60
I feel overwhelmed every day.
0
1
2
3
Question 2 of 60
I am or have been an emotional eater.
Question 3 of 60
I currently have or have had an eating disorder (anorexia, bulimia, binging, etc.).
Question 4 of 60
I am a sensitive person to other people’s energy and trauma.
Question 5 of 60
I am highly sensitive to loud noises and lights in my environment.
Question 6 of 60
I startle easily and it seems over-reactive.
Question 7 of 60
I have a low tolerance for stress. Small things stress me out.
Question 8 of 60
My reactions to triggers are either over-reactive or I paralyze and don’t respond.
Question 9 of 60
I use coping mechanisms, including an addiction, to self-soothe and escape.
Question 10 of 60
I don’t feel like myself. I can feel disconnected from others and even myself.
Question 11 of 60
I have a hard time falling asleep at night
Question 12 of 60
I experience abdominal pain that changes with eating, bowel movements or throughout the day.
Question 13 of 60
I experience symptoms of constipation and/or diarrhea on a regular basis.
Question 14 of 60
I experience a chronic skin condition that changes with foods or stress (rashes, eczema, acne).
Question 15 of 60
After eating, I can feel tired, depressed, get a headache or can’t focus.
Question 16 of 60
I have or have had a diagnosis of bowel disease of IBS, Crohn’s or Ulcerative Colitis.
Question 17 of 60
There are things in my life I have not yet fully grieved.
Question 18 of 60
These foods are part of my regular diet: gluten, highly processed foods and non-organic foods.
Question 19 of 60
I get irritable at people, places or things that take up more time and energy than I planned.
Question 20 of 60
I experience daily fatigue or sense of heaviness and exhaustion.
Question 21 of 60
I experience heaviness and low energy in the morning and don’t want to start my day.
Question 22 of 60
I multi-task to stay active and out of the heaviness.
Question 23 of 60
I reach for things that will give me quick energy to get through my day.
Question 24 of 60
I always see danger and am on the defensive.
Question 25 of 60
I consider myself an adrenaline junkie or seek excitement to feel alive.
Question 26 of 60
I experience uncontrollable craving for sweets and carbs.
Question 27 of 60
I have a poor active working memory (e.g. forgetfulness in the middle of a task, don’t remember when I just put my keys or my drink).
Question 28 of 60
I experience anxiety.
Question 29 of 60
I experience depression.
Question 30 of 60
I am on or have been on mood medications.
Question 31 of 60
I have had a major surgery requiring anesthesia.
Question 32 of 60
I experience an energy crash after either exercising or after something emotional.
Question 33 of 60
I have a chronic health issue (1 for 1 health issue, 3 is 3 or more chronic health issues).
Question 34 of 60
I have long-haul symptoms of infections (mold, lyme, viral infections, etc.).
Question 35 of 60
I have an autoimmune condition.
Question 36 of 60
I have a chronic health issue that affects my breathing (bloating, asthma, heart disease, etc.)
Question 37 of 60
I am on a number of prescription medications for my chronic health issues.
Question 38 of 60
I am underweight, overweight or obese.
Question 39 of 60
I have thyroid problems (ie. hypothyroidism or hyperthyroidism).
Question 40 of 60
I have adrenal gland problems (ie. adrenal fatigue).
Question 41 of 60
I have a chronic nutrient or vitamin deficiency.
Question 42 of 60
I have or have been diagnosed with a cancer.
Question 43 of 60
I have bags under my eyes when I wake up.
Question 44 of 60
I wake up during the night and can’t fall back asleep within 20 minutes.
Question 45 of 60
I know I have a methylation imbalance.
Question 46 of 60
I seem to have a weak immune system and get sick more often than I think is healthy.
Question 47 of 60
I experience opposite reactions to treatments and supplements than what is expected.
Question 48 of 60
I put myself under pressure to get things done.
Question 49 of 60
I have had the thought that if people really knew me, they wouldn’t like me and would leave.
Question 50 of 60
I experience flairs of chronic back or neck pain.
Question 51 of 60
I hold myself back because I don’t trust myself to follow through.
Question 52 of 60
If I am honest with myself, I feel empty inside.
Question 53 of 60
I notice I do not enjoy relaxing and playing. I find myself still stressed.
Question 54 of 60
I prefer to keep emotions out of it and overthink things and conversations.
Question 55 of 60
I have scoliosis or had bow legs as a child.
Question 56 of 60
My body and muscles feel tight and stay tight.
Question 57 of 60
I had birth trauma (born prematurely, born with cord around neck, went to NICU, etc.)
Question 58 of 60
I experienced a significant disruption during the first 5 years of my life (abandonment, adoption, loss of a parent, medical trauma, etc.)
Question 59 of 60
I would rate my level of feeling scared and alone during my childhood until age 12 was.
Question 60 of 60
My relationship patterns in my life are to either hold on too tight or to let go and push away.