Are you more forgetful than usual—losing things, missing appointments, or forgetting what you are doing or saying?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you depressed for no apparent reason? Have you lost motivation and interest in things you used to enjoy?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you more anxious or worried than usual? Do you get anxiety or panic attacks or feel a general, constant sense of unease or foreboding?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have “brain fog,” or more difficulty concentrating and focusing or staying with one task to completion than usual?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you experience unexplained mood swings?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you say words you don’t mean to say, or call things by the wrong name, and notice only after you say it or when someone else points it out?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have sensory issues—i.e., are you experiencing sound, light, or touch in a different way than is normal for you?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Have you been diagnosed with (or do you suspect you have) mild cognitive decline, and/or do you have a family history of dementia, such as Alzheimer’s disease?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you often bloated or gassy, and/or does your stomach get distended after or between meals, so that you look pregnant?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have diarrhea or loose, watery stool that is difficult to control or comes on suddenly?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you get constipated, or go more than twentyfour hours without having a bowel movement, or do you have hard, dry stool that is difficult to pass, resembling small pellets?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have alternating diarrhea and constipation more often than normal (firm but soft and easy to pass) stools?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have alternating diarrhea and constipation more often than normal (firm but soft and easy to pass) stools?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you get heartburn or acid reflux after eating, when you’ve gone too long without eating, and/or at night?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Is your tongue covered with a fuzzy-looking coating, and/or do you have chronic bad breath even when you practice good oral hygiene?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Does your stomach hurt or cramp, or do you feel sick or nauseated, after eating, whether or not you can associate this with any particular food?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you get uncomfortable stomach or other gastric symptoms (like gas, bloating, or diarrhea) when you are experiencing extreme emotions, such as nervousness, fear, or anxiety?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you retain water easily, and/or feel like your body looks much larger on some days and much smaller and tighter on other days, in a way too extreme or sudden to be related to fat gain or loss? If you press your finger into your lower leg, does it leave a pit for a few seconds?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Does your weight fluctuate more than five pounds from morning to evening or from one day to the next?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Have you been diagnosed with any chronic infections such as mold toxicity, Lyme disease, or viral infection?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have a vague feeling of “being toxic,” even if you can’t pin it on any particular symptom?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Have you noticed a yellowish tint to your skin or the whites of your eyes?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have abdominal tenderness that seems unrelated to eating, especially in the upper right quadrant of your torso, or that spreads to your upper back or shoulder?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Does your urine tend to be dark yellow, and/or does your stool tend to float?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have unexplained itching, flaking, or rashes on your hands and/or feet?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you crave sugary or starchy foods even when you have already eaten enough or feel full (such as after a big meal or too soon between meals)?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Have you noticed an increase in appetite and/or thirst and urination recently?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you get blurred vision that comes and goes?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you unusually tired even if you got enough sleep but notice that your fatigue is relieved by eating something?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you feel light-headed, dizzy, shaky, jittery, irritable, or “hangry” (a combination of hungry and angry) when you haven’t eaten for a few hours or you skip a meal?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Is your waist girth equal to or greater than your hip girth?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have difficulty losing weight, even when cutting calories and/ or exercising?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Have you had your fasting blood sugar tested and it was 100 dl/ml or higher, and/or have you had a hemoglobin A1C test and it was 5.7 or above, and/or do you have a diagnosis of prediabetes, metabolic syndrome, or type 2 diabetes?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you tend to have fatigue and/or headaches in the afternoons, then get a second wind in the evening, which causes you to stay up late?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you feel dizzy when you stand up suddenly?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you often crave salty foods?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are your hands and feet often cold, even when your environment is warm?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you sleep excessively, or feel as if you could sleep all day and still sleep at night?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are the outer thirds of your eyebrows thinning or missing?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Has your sex drive disappeared? Are you rarely if ever “in the mood”?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

For women: Are you experiencing irregular, painful, or unusually heavy menstrual periods? For men: Have you recently experienced any new occurrence of erectile dysfunction?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do your joints hurt periodically, constantly, or in flares, in random places, with the pain coming and going, seemingly unrelated to injuries?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you hypermobile, “double-jointed,” or are your joints hyper-flexible?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you accidentprone, often twisting your ankle, tripping or falling, or dropping things? Do you consider yourself clumsy? Do you often injure your tendons and/or ligaments?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do your joints constantly pop, crack, snap, or get stuck in certain positions?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you wake up with stiff and/or aching joints and/or muscles but can relieve the stiffness by movement, only to find that it returns at the end of an active day?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have chronic neck or back pain, tightness, and tension?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you get pins and needles, random stabbing pains, and/ or numbness in your hands and feet, or shooting pains down your arms or legs?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are massages painful, especially in your arms, legs, and buttocks?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you experiencing obvious extreme reactions to certain foods or after eating—reactions such as vomiting, diarrhea, pain, skin reactions, or neurological episodes like brain fog or panic attacks?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you intolerant to cold or heat, and/or do your hands or feet turn bluish or gray when they are cold? And/or are your skin, mouth, or eyes unusually dry?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have a family history of autoimmune issues, such as rheumatoid arthritis, lupus, multiple sclerosis, celiac disease, inflammatory bowel disease/Crohn’s disease, or Hashimoto’s thyroiditis?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have joint pain and swelling, and/or numbness and tingling, bilaterally (in the same place on both sides of your body, such as in both hands, elbows, knees, and/or feet)?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have unexplained rashes, chronic acne, or recurring boils or cystic acne on your face or body?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Do you have extreme, constant, unrelenting fatigue that cannot be relieved by sleeping, eating, or other remedies?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are you having unexplained muscle weakness, or have you noticed that your foot is dragging or you are dropping things more often?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4

Are any of the above symptoms episodic, flaring up, sometimes to an extreme degree, then dying down for a while, only to return days, weeks, or even months later?

NEVER=0

RARELY=1

SOMETIMES=2

OFTEN=3

ALWAYS=4