In the past week, please rate each area as follows

0
1
2
3
4

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Never or almost never have the symptom

Occasionally have it, effect is not severe
Occasionally have it, effect is severe
Frequently have it, effect is not severe
Frequently have it, effect is severe

Health Area
Bad Odors
Underarms
Breathe
Feet
Crotch
Gas
Subtotal
Body Heat/Sweating
Sweaty palms or feet
Sweat easily/excessive sweating
Cold sweats often
Night sweats
Easily chilled
Low tolerance to cold weather
Extremities get cold easily (especially hands and feet)
Hot flashes
Subtotal
Face
Large pore size
Wrinkles/fine lines
Puffiness
Oily
Dry
Rosacea/flushed
Subtotal

Skin
Discolored/purple
Acne/pimples/eczema
Itching
Scaly/dryness/roughness/ cracking/ psoriasis
Looseness/Flappiness
Bruise easily
Skin tags/Cysts
Brown/sun spots
Hives/rashes
Sores
Cellulite/dimples/saggy shadows
Stretch marks
Poor muscle tone
Varicose veins
Numbness
Tingling
Searing pain
Subtotal
Mental
Difficulty concentrating or focusing
Trouble remembering things/forgetfulness
Tend to procrastinate
Brain fog/slow thinking
Lack of attention to detail
Trouble delaying what you want/needs instant gratification
Trouble listening
Problems getting organized
Restless/hyperactive
Difficulty making decisions
Stuttering/stammering
Slurred speech
Confusion, poor comprehension
Poor physical coordination

Subtotal
Mood
Anger/irritability
Agitated/restless
Anxiety/stress/worry
Short tempered/short fuse
Sadness/depression
Negative thinking
Low interest in things normally pleasurable
Mood swings/unstable mood
Low self-esteem/lack of confidence/worthlessness
Lack of desire to socialize
Lack of feeling anything/apathy
Subtotal
Energy
Exhausted/fatigued/sluggish
Apathy/lethargy
Lack of motivation to exercise
Energy crashes/drowsy in mid- to late afternoon
Drawn to caffeine, sugar/sweets or carbs for energy
Low energy or drowsy after meals
Subtotal
Sleep
Trouble getting to sleep
Trouble staying asleep
Don't get enough sleep
Wake up feeling tired
Sleep not restful
Excessive snoring or sleep apnea
Wake up between 2 a.m. - 4 a.m. for 15 minutes or longer
Subtotal
Joints and Muscles

Aches/pains/soreness
Stiffness
Mobility/flexibility
Arthritis
Limitation of movement
General feeling of weakness/lack of strength
Subtotal
Cravings
Sugar/sweets
Simple carbs such as bread, pasta
Fatty Foods
Salty foods
Dairy (milk, ice cream, yogurt, cheese, etc.)
Alcohol
Coffee
Drugs
Subtotal
Hunger/Appetite
Get agitated or angry between meals
Can't go more than 3 hours without eating
Lightheaded if meals are missed
Eating relieves fatigue
Eat to relieve depression or sadness
Skip meals often
Eat late at night or before bed
Wake up in middle of night hungry
Frequently binge eat
Trouble stopping eating even when full
Need to snack often
Compulsive eating
Subtotal
Digestion
Passing gas

Burping
Bloating
Stomach/abdominal pain
Acid reflux
Heartburn/GERD
Cramping
Nausea/upset stomach
IBS
Subtotal
Hair
Hair loss
Dryness
Thinning
Dandruff/flaky scalp
Dry scalp
Itchy scalp
Red scalp
Subtotal
Head
Headaches/migraines
Faintness
General Dizziness
Lightheaded, especially when getting up
Shaky
Subtotal
Nose
Trouble breathing
Runny nose
Stuffy nose
Post nasal drip
Sinus problems
Hay fever
Sneezing attacks

Excessive mucus formation

Subtotal
Ears
Itchy ears
Earaches/ear infections
Drainage
Trouble hearing
Ear pressure
Ringing/tinnitus
Subtotal
Eyes
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Burning sensation
Muscle twitching around eyes
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near-or far-sightedness)
Sensitive to light
Impaired night vision
Subtotal
Nails
Weak
Cracked or split
Ridged/ripled
Puffy nail fold
Gnawed nails
Yellowish/whitish/bluish/pale color
Subtotal
Mouth/Throat
Soreness
Itchiness
Chronic coughing

Difficulty swallowing
Gagging reflex
Frequent need to clear throat
Hoarseness, or loss of voice
Swollen or discolored tongue, gum, or lips
Canker sores
Overall sense of taste
Dry mouth
Frequent thirst
Subtotal
Lungs
Shortness of breath
Labored/difficult breathing
Asthma/bronchitis
Sneezing attacks
Wheezing when breathing
Congestion
Subtotal
Heart
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Heart palpitations/racing heart
Chest pain
Fast pulse rate at rest
Pulse increases after eating
Rapid pulse before bed
Subtotal
Elimination
Frequent urination
Pain urinating
Urgent urination
Wake frequently to urinate
Stool unusual in color, shape or consistency

Hard stool
Foul-smelling stool
Diarrhea
Constipation
Subtotal
Other
Genital itching/discharge
Tender lymp nodes
Itchy or stinging anus
Irregular periods
Bad PMS symptoms
Recurring yeast infections
Chronic fungus on nails, skin or athlete's foot
Lack of sex drive
Frequently ill or get colds, flu, viruses, etc.
Subtotal

DO NOT ENTER ANYTHING IN THE FIELDS BELOW -- TH

Grand Total
# Difference to Day 1
% Difference to Day 1

IMPORTANT: Take your first measurements the Sunday before start, th

Beginning Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

BELOW -- THESE WILL AUTOMATICALLY CALCULATE TO SHOW YOUR PROGRESS

N/A
N/A
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

before start, then weekly on every Sunday on through to your final measureme
Week 7 Week 8 Week 9

OUR PROGRESS
#DIV/0! #DIV/0! #DIV/0!

our final measurements at the END of week 9.

INSTRUCTIONS: Enter your measurement in inches below

Beginning Week 1 Week 2 Week 3
Hips
Waist
Chest
Bust
Thigh
Calve
Upper Arm
Forearm
Neck

DO NOT ENTER ANYTHING IN THE FIELDS BELOW -- THESE WILL AU

Total
# Difference to Day 1
N/A
% Difference to Day 1
N/A
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Week 4 Week 5 Week 6 Week 7 Week 8 Week 9

3

- THESE WILL AUTOMATICALLY CALCULATE TO SHOW YOUR PROGRESS

#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

ROGRESS

INSTRUCTIONS: Enter your weight below and your height to the right-Beginning Week 1 Week 2 Week 3
Weight (enter here)
BMI (don't enter)

#DIV/0!

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DO NOT ENTER ANYTHING IN THE FIELDS BELOW -- THESE WIL

# Difference to Day N/A
% Difference to Day N/A
#DIV/0! #DIV/0! #DIV/0!

height to the right-- BMI will automatically calculate

Week 4 Week 5 Week 6 Week 7 Week 8 Week 9
#DIV/0!

#DIV/0!

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#DIV/0!

#DIV/0!

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BELOW -- THESE WILL AUTOMATICALLY CALCULATE TO SHOW YOUR PROGRESS

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Height (in inches)

YOUR PROGRESS

<== Put your height in inches here

ches here

INSTRUCTIONS -- Enter a 1 ONLY if you generally agree with the statem

I am very hungry first thing in the morning.

I need coffee/caffeine to get going in the morning.
I usually drink more than one cup of coffee or cola a day.
I have a difficult time maintaining my ideal weight.
I cant easily go more than 3-4 hours without getting hungry.
Eating often relieves my fatigue.
I often get moody or irritable before meals.
I often feel weak or dizzy if I wait more than 3-4 hours to eat.
I often crave sweets and/or caffeine between meals.
I often get "shaky" when Im hungry.
I suffer from frequent fatigue or fuzzy thinking that eating relieves.
I frequently nibble food between meals because of hunger.
I crave candy or coffee/caffeine in afternoons
Im often tired or drowsy at work.
I get anxious and/or depressed when Im hungry.
Once I begin eating sweets, it is very difficult for me to stop.
I prefer sweets and starches over all other kinds of food.
I cant fall asleep at night without a snack before bed.
I frequently awake in the middle of the night hungry.
If I awake at night, I cant easily go back to sleep without a snack.

DO NOT ENTER ANYTHING IN THE FIELDS BE

Total
# Difference to Day 1
% Difference to Day 1

he statement; if not, enter a 0

Beginning Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

FIELDS BELOW -- THESE WILL AUTOMATICALLY CALCULATE TO SHOW YOUR PRO

N/A
N/A
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Week 7 Week 8 Week 9

HOW YOUR PROGRESS

#DIV/0! #DIV/0!

#DIV/0!