Section 1: Check all symptoms you are currently experiencing 3 or more times per week.
Brown spots on backs of hands and throughout body
Burping or belching after eating
Excessive menstrual bleeding
Hot flashes
Craving starches and sweets (regularly)
Difficulty making decisions
Brain fog or cognitive issues
Dowager’s hump (fat pad) at the upper back, lower neck area
None of these apply
Section 2: Check all symptoms you are currently experiencing 3 or more times per week.
Arthritis
Bloating after eating
Cravings at certain times of the month
Depression during menstrual cycle (women)
Brittle nails and vertical ridges (could be thick)
Cold intolerance (need to put on a sweater or more covers while sleeping)
Acne or poor skin
Joint pain
None of these apply
Section 3: Check all symptoms you are currently experiencing 3 or more times per week.
Sluggish bowel movement
Cravings for fried foods and sour foods
Infertility
Lower Back or hip pain
Dry skin
Fatigue
Depression
Facial hair
None of these apply
Section 4: Check all symptoms you are currently experiencing 3 or more times per week.
Eyelids itchy and/or swollen
Gallbladder problems
Mood swings
Night sweats
Generalized weight gain
Hair loss or thinning hair
Fatigue
Increased susceptibility to viruses and illness
None of these apply
Section 5: Check all symptoms you are currently experiencing 3 or more times per week.
Headaches
High blood pressure
Ovarian cysts
PMS
High cholesterol
Indentations on sides of tongue
Insomnia
Low sex drive / libido
None of these apply
Section 6: Check all symptoms you are currently experiencing 3 or more times per week.
Hives and itchiness
Little red dots on skin
Reoccurring acne
Reoccurring brain fog
Lethargy
Loss of libido
Midsection weight gain
Moodiness and irritability
None of these apply
Section 7: Check all symptoms you are currently experiencing 3 or more times per week.
Liver roll of fat (just below the rib cage), seen mostly in women
Pain or tightness in right shoulder area
Reoccurring constipation
Reoccurring fatigue
Low body temperature
Outer eyebrows thinning or absent
Needs coffee to wake up
Compromised immune system
None of these apply
Section 8: Check all symptoms you are currently experiencing 3 or more times per week.
Poor joints
Potbelly (very little external fat, mostly fluid)
Chronic knee pain
Chronic low back or hip pain
Poor short-term memory and focus
Puffiness around eyes
Poor circulation
Reddish purple stretch marks on the stomach, thighs, buttocks, arms and breasts
None of these apply
Section 9: Check all symptoms you are currently experiencing 3 or more times per week.
Skin problems
Tongue coated with white film
Reoccurring low libido
Thinning of the hair
Sagging skin under arms, chin or midsection
Slight rosiness or reddening of the face
Round or moon face
Salt, cheese, chocolate and/or sugar cravings late afternoon and evening
None of these apply
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