| |
| CATEGORY I |
| Feeling that bowels do not empty completely |
0
1
2
3 |
| Lower abdominal pain relief by passing stool or gas |
0
1
2
3 |
| Alternating constipation and diarrhea |
0
1
2
3 |
| Diarrhea |
0
1
2
3 |
| Constipation |
0
1
2
3 |
| Hard dry or small stool |
0
1
2
3 |
| Coated tongue of "fuzzy" debris on tongue |
0
1
2
3 |
| Pass large amount of foul smelling gas |
0
1
2
3 |
| More than 3 bowel movements daily |
0
1
2
3 |
| Use laxatives frequently |
0
1
2
3 |
| |
|
| CATEGORY II |
0
1
2
3 |
| Excessive belching, burping, or bloating |
0
1
2
3 |
| Gas immediately following a meal |
0
1
2
3 |
| Offensive breath |
0
1
2
3 |
| Difficult bowel movements |
0
1
2
3 |
| Sense of fullness during and after meals |
0
1
2
3 |
| Difficulty digesting fruits and vegetables;
undigested foods found in stools |
0
1
2
3 |
| |
|
| CATEGORY III |
|
| Stomach pain, burning or aching 1 - 4 hours after eating |
0
1
2
3 |
| Do you frequently use antacids |
0
1
2
3 |
| Feeling hungry an hour or two after eating |
0
1
2
3 |
| Heartburn when lying down or bending forward |
0
1
2
3 |
| Temporary relief from antacids, food, milk, carbonated beverages |
0
1
2
3 |
| Digestive problems subside with rest and relaxation |
0
1
2
3 |
| Heartburn due to spicy foods, chocolate, citrus,
peppers, alcohol, and caffeine |
0
1
2
3 |
| |
|
| CATEGORY IV |
|
| Roughage and fiber cause constipation |
0
1
2
3 |
| Indigestion and fullness lasts 2-4
hours after eating |
0
1
2
3 |
| Pain, tenderness, soreness on left side
under rib cage |
0
1
2
3 |
| Excessive passage of gas |
0
1
2
3 |
| Nausea and/or vomiting |
0
1
2
3 |
| Stool undigested, foul smelling,
mucous-like, greasy, or poorly formed |
0
1
2
3 |
| Frequent urination |
0
1
2
3 |
| Increased thirst and appetite |
0
1
2
3 |
| |
|
| CATEGORY V |
|
| Greasy or high fat foods cause distress |
0
1
2
3 |
| Lower bowel gas and or bloating
several hours after eating |
0
1
2
3 |
| Bitter metallic taste in mouth,
especially in the morning |
0
1
2
3 |
| Unexplained itchy skin |
0
1
2
3 |
| Yellowish cast to eyes |
0
1
2
3 |
| Stool color alternates from clay colored
to normal brown |
0
1
2
3 |
| Reddened skin, especially palms |
0
1
2
3 |
| Dry or flaky skin and/or hair |
0
1
2
3 |
| History of gallbladder attacks or stones |
0
1
2
3 |
| Have you had your gallbladder removed |
0
1
2
3 |
| |
|
| CATEGORY VI |
|
| Crave sweets during the day |
0
1
2
3 |
| Irritable if meals are missed |
0
1
2
3 |
| Depend on coffee to keep yourself going or started |
0
1
2
3 |
| Get lightheaded if meals are missed |
0
1
2
3 |
| Eating relieves fatigue |
0
1
2
3 |
| Feel shaky, jittery, tremors |
0
1
2
3 |
| Agitated, easily upset, nervous |
0
1
2
3 |
| Poor memory, forgetful |
0
1
2
3 |
| Blurred vision |
0
1
2
3 |
| |
|
| CATEGORY VII |
|
| Fatigue after meals |
0
1
2
3 |
| Crave sweets during the day |
0
1
2
3 |
| Eating sweets does not relieve cravings for sugar |
0
1
2
3 |
| Must have sweets after meals |
0
1
2
3 |
| Waist girth is equal or larger than hip girth |
0
1
2
3 |
| Frequent urination |
0
1
2
3 |
| Increased thirst & appetite |
0
1
2
3 |
| Difficulty losing weight |
0
1
2
3 |
| |
|
| CATEGORY VIII |
|
| Cannot stay asleep |
0
1
2
3 |
| Crave salt |
0
1
2
3 |
| Slow starter in the morning |
0
1
2
3 |
| Afternoon fatigue |
0
1
2
3 |
| Dizziness when standing up quickly |
0
1
2
3 |
| Afternoon headaches |
0
1
2
3 |
| Headaches with exertion or stress |
0
1
2
3 |
| Weak nails |
0
1
2
3 |
