Glandular and Digestive Imbalances Questionnaires

Take a self test to determine if you have the many influences that cause the symptoms of  a hiatal hernia? Please indicate by selecting from one of the following: 0 = Never / Rarely;  1 = Occasionally / Slightly, 2 = Moderate in Intensity or Frequency;  3 = Intense, Severe or Frequent;, 4 = Current symptoms

 Category One

0 1 2 3 4    1-1 Feeling the bowels don't empty completely?

0 1 2 3 4    1-2 Lower abdominal pain relief by passing stool or gas?

0 1 2 3 4    1-3 Alternating constipation or diarrhea? 

0 1 2 3 4    1-4 Diarrhea?

0 1 2 3 4    1-5 Constipation

0 1 2 3 4    1-6 Hard dry or small stool?

0 1 2 3 4    1-7 Coated tongue of "fuzzy" debris on tongue?

0 1 2 3 4    1-8 Pass large amounts of foul smelling gas?

0 1 2 3 4    1-9 More than 3 bowel movements daily?

0 1 2 3 4    1-10 Do you use laxatives frequently?   

Category Two

0 1 2 3 4    2-1. Excessive belching, burping or bloating?

0 1 2 3 4    2-2. Gas immediately following a meal?

0 1 2 3 4    2-3. Offensive breath?

0 1 2 3 4    2-4. Difficult Bowel Movements?

0 1 2 3 4    2-5. Sense of fullness during and after meals?

0 1 2 3 4    2-6. Difficulty digesting fruits and vegetables; undigested food found in stool?

Category Three

0 1 2 3 4    3-1. Stomach pain, burning or aching 1-4 hours after eating ?

0 1 2 3 4    3-2. Do you frequently use antacids?

0 1 2 3 4    3-3. Feeling hungry an hour or to after eating?

0 1 2 3 4    3-4. Heartburn when lying down or bending forward?

0 1 2 3 4    3-5. Temporary relief from antacids, food, milk, carbonated beverages?

0 1 2 3 4    3-6. Digestive problems subside with rest and relaxation?

0 1 2 3 4    3-7. Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine?

Category Four

0 1 2 3 4    4-1. Roughage and fiber cause constipation?

0 1 2 3 4    4-2. Indigestion an fullness lasts 2-4 hours after eating?

0 1 2 3 4    4-3. Pain, tenderness, soreness, on left side under rib cage bloated?

0 1 2 3 4    4-4. Excessive passage of gas?

0 1 2 3 4    4-5. Nausea and / or vomiting?

0 1 2 3 4    4-6. Excessive passage of gas?

0 1 2 3 4    4-7. Stool undigested, foul smelling, mucous-like, greasy or poorly formed?

0 1 2 3 4    4-8. Frequent urination?

0 1 2 3 4    4-9. Increased thirst and appetite?

Category Five

0 1 2 3 4    5-1. Greasy or high fat foods cause distress?

0 1 2 3 4    5-2. Lower bowel gas and bloating several hours after meals?

0 1 2 3 4    5-3. Bitter metallic taste in mouth, especially in the morning?

0 1 2 3 4    5-4. Unexplained itchy skin?

0 1 2 3 4    5-5. Yellowish cast to the eyes?

0 1 2 3 4    5-6. Stool alternates from clay color to normal brown?

0 1 2 3 4    5-7. Reddened skin, especially palms?

0 1 2 3 4    5-8. Dry or flaky skin and or hair?

0 1 2 3 4    5-9. History of Gall Bladder attacks or stones?

0 1 2 3 4    5-10. Have you had your gall bladder removed?

Category Six

0 1 2 3 4    6-1. Crave sweets during the day?

0 1 2 3 4    6-2. Irritable if meals are missed?

0 1 2 3 4    6-3. Depend on coffee to keep yourself going or started?

0 1 2 3 4    6-4. Get lightheaded if meals are missed?

0 1 2 3 4    6-5. Eating relieves fatigue?

0 1 2 3 4    6-6. Feel shaky, jittery, tremors?

0 1 2 3 4    6-7. Agitated, easily upset, nervous?

0 1 2 3 4    6-8. Poor memory, forgetful?

0 1 2 3 4    6-9. Blurred vision?

Category Seven

0 1 2 3 4    7-1. Fatigue after meals?

0 1 2 3 4    7-2. Crave sweets during the day?

0 1 2 3 4    7-3. Eating sweets does relieve craving for sugar?

0 1 2 3 4    7-4. Must have sweets after meals?

0 1 2 3 4    7-5. Waist girth is equal or larger than the hip girth?

0 1 2 3 4    7-6. Frequent urination?

0 1 2 3 4    7-7. Increased thirst and appetite?

0 1 2 3 4    7-8. Difficulty loosing weight?

Category Eight

0 1 2 3 4    8-1. Cannot stay asleep?

0 1 2 3 4    8-2. Crave Salt?

0 1 2 3 4    8-3. Slow starter in the morning?

0 1 2 3 4    8-4. Afternoon fatigue?

0 1 2 3 4    8-5. Dizziness when standing up quickly?

0 1 2 3 4    8-6. Afternoon headaches?

0 1 2 3 4    8-7. Headaches with exertion of stress?

Category Nine

0 1 2 3 4    9-1. Cannot fall asleep?

0 1 2 3 4    9-2. Perspire easily?

0 1 2 3 4    9-3. Under high amount of stress?

0 1 2 3 4    9-4. Weight gain under stress?

0 1 2 3 4    9-5. Excessive perspiration with little or no activity?

Category Ten

0 1 2 3 4    10-1. Tired, sluggish?

0 1 2 3 4    10-2. Feel cold - hands,, feet, cold all over?

0 1 2 3 4    10-3. Require excessive amounts of sleep to function properly? 

0 1 2 3 4    10-4. Increase in weight gain even on low calorie diet?

0 1 2 3 4    10-5. Gain weight easily?

0 1 2 3 4    10-6. Difficult, infrequent bowel movement?

0 1 2 3 4    10-7. Depression, lack of motivation?

0 1 2 3 4    10-8. Morning headaches that wear off as the day progresses?

0 1 2 3 4    10-9. Outer third of eyebrow thins? 

0 1 2 3 4    10-10. Thinning of hair on scalp, face, genitals or excessive falling of hair?

0 1 2 3 4    10-11. Dryness of skin and or scalp?

0 1 2 3 4    10-12. Mental sluggishness? 

Category Eleven

0 1 2 3 4    11-1. Heart palpitations?

0 1 2 3 4    11-2. Inward trembling?

0 1 2 3 4    11-3. Increased pulse even at rest?

0 1 2 3 4    11-4. Nervousness an emotional? 

0 1 2 3 4    11-5. Insomnia? 

0 1 2 3 4    11-6. Night Sweats?

0 1 2 3 4    11-7. Difficulty gaining weight?

Category Twelve

0 1 2 3 4    12-1. Diminished sex drive?

0 1 2 3 4    12-2. Menstrual disorders or lack of menstruation?

0 1 2 3 4    12-3. Increased ability to eat sugars without symptoms  ?

Category Thirteen

0 1 2 3 4    13-1. Increased sex drive?

0 1 2 3 4    13-2. Tolerance to sugars reduced. 

0 1 2 3 4    13-3. Splitting type headaches?    

Category Fourteen  (Males Only)

0 1 2 3 4    14-1 Urination difficulty or dribbling

0 1 2 3 4    14-2 Urination frequent

0 1 2 3 4    14-3 Pain inside of legs or heels

0 1 2 3 4    14-4 Feeling of incomplete bowel evacuation

0 1 2 3 4    14-5 Leg nervousness at night  

Category Fifteen (Males Only)

0 1 2 3 4    15-1 Decrease in libido

0 1 2 3 4    15-2 Decrease in spontaneous morning erections

0 1 2 3 4    15-3 Decrease in fullness of erections

0 1 2 3 4    15-4 Difficulty in maintaining morning erections

0 1 2 3 4    15-5 Spells of mental fatigue

0 1 2 3 4    15-6 Inability to concentrate

0 1 2 3 4    15-7 Episodes of depression

0 1 2 3 4    15-8 Muscles soreness

0 1 2 3 4    15-9 Decrease in physical stamina

0 1 2 3 4    15-10 Unexplained weight gain

0 1 2 3 4    15-11 Increase in fat distribution around chest and hips

0 1 2 3 4    15-12 Sweating attacks

0 1 2 3 4    15-13 More emotional than in the past

Category Sixteen (Menstruating Females Only)

0 1 2 3 4    16-1 Are you menopausal?

0 1 2 3 4    16-2 Alternating menstrual cycles

0 1 2 3 4    16-3 Extended menstrual cycle, greater than 32 days

0 1 2 3 4    16-4 Shortened menses, less than 24 days

0 1 2 3 4    16-5 Pain and cramping during periods

0 1 2 3 4    16-6 Scanty blood flow

0 1 2 3 4    16-7 Heavy blood flow

0 1 2 3 4    16-8 Breast pain and swelling during menses 

0 1 2 3 4    16-9 Pelvic pain during menses

0 1 2 3 4    16-10 Irritable and depressed during menses

0 1 2 3 4    16-11 Acne break outs

0 1 2 3 4    16-12 Facial hair growth

0 1 2 3 4    16-13 Hair loss / thinning

Category Seventeen 

0 1 2 3 4    17-1 How many years have you been menopausal?

0 1 2 3 4    17-2 Do you ever have uterine bleeding since menopause?

0 1 2 3 4    17-3 Hot flashes

0 1 2 3 4    17-4 Mental fogginess

0 1 2 3 4    17-5 Disinterest in sex

0 1 2 3 4    17-6 Mood swings

0 1 2 3 4    17-7 Depression

0 1 2 3 4    17-8 Painful intercourse

0 1 2 3 4    17-9 Shrinking breasts

0 1 2 3 4    17-10 Facial hair growth

0 1 2 3 4    17-11 Acne

0 1 2 3 4    17-12 Increased vaginal, pain, dryness or itching

If you answer "YES"  which equal a 1, 2, 3, or 4 answer to more than twelve  questions, you have tendencies toward  digestive and hormonal imbalances. There are multiple causes, and multiple energies that can contribute to these imbalances: structural changes in the spine, cranium and autonomic nerve system, allergies, hiatal hernia, bowel problems, imbalances in the adrenals creating high cortisol levels, individual glands like thymus - immune system, thyroid - metabolic changes, pituitary communication (master gland) breakdown with the rest of the body, hypothalamus (nerve communication) not communicating with the pituitary, blood flow changes to the brain or digestive tract. All of these can alter the production, assimilation, and distribution of hormones and processing our food. 

 After taking the test above, send the results to us with the information below. We'll get back to you by E-mail within a week. We will give you an overview and a new perspective of what can be done. Or you can call our office for an appointment and consultation. 706-379-1225

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