8 Weeks to Vibrant Health: A Woman's Take Charge P

General Health Questionnaire

Fill out the entire questionnaire. It’s important to do all the sections, even if you think they don’t apply to you. You’ll notice that some of the same symptoms are involved in several imbalances.

List your major symptoms:

In each of the following sections, put a check mark next to the symptoms that apply to you:

Section 1: Lifestyle and Stress

__ Difficulty relaxing

__ Irritability

__ Insomnia

__ Tension headaches

__ Impatience

__ Sense of isolation from others

__ Taking on too much responsibility

__ Difficulty delegating

__ Recent major life change (marriage, divorce, birth of child, death of close relative, purchase of home, new job, loss of job, etc.)

Section 2: Brain Chemistry

__ Headaches

__ Excessive fatigue

__ Low energy

__ Weight gain/difficulty losing weight

__ Memory loss/difficulty concentrating

__ Sustained high stress level

__ Nervousness

__ Depression

__ Crying easily and often

__ Anxiety, irritability

Section 3: Sex Hormones

Note all of the symptoms that apply to you within two weeks before your period:

__ Weight gain

__ Depression, anxiety, irritability

__ Sore or swollen breasts

__ Abdominal bloating or swelling

__ Lower backache

__ Craving for sweets

__ Headaches

__ Vaginal itching

__ Recurrent vaginal discharge

__ Irregular periods

__ Breast lumps (fibrocystic breasts)

__ Intensification of other premenstrual syndrome (PMS) symptoms

__ Bad cramps n Heavy bleeding

Note all of the symptoms that apply to you if you are experiencing menopause or perimenopause:

__ Hot flashes, night sweats

__ Mood swings, irritability

__ Insomnia

__ Erratic or missed periods

__ Dry skin, hair, vagina

__ Painful intercourse

__ Known or suspected osteoporosis

__ Joint pain

__ Fibromyalgia

__ Hysterectomy

__ Loss of interest in sex

Section 4: Thyroid and Adrenals

Thyroid

__ Excessive fatigue, especially first thing in the morning

__ Weight gain/difficulty losing weight

__ Dry skin

__ Dry, brittle hair

__ Constipation

__ Easily chilled; cold and/or numb hands, feet

__ Forgetfulness

__ Low sex drive

__ Depression

__ Outer third of eyebrow missing or thinning

Low Adrenal Function

__ Excessive fatigue

__ Inhalant allergies such as dust, mold, asthma, hay fever

__ Sensitivity to smog, fumes, and smoke

__ Trouble falling asleep and, even more, staying asleep

__ Low blood pressure

__ Craving for salty foods

__ Sensitivity to weather changes

__ Dizziness when standing up suddenly

__ Dark blue or black circles under eyes

__ Susceptibility to colds or infections

__ Puffy and swollen body (water retention)

Section 5: Blood Sugar

__ Hypoglycemia (low blood sugar)

__ Excessive fatigue

__ Dizziness when standing up quickly

__ Irritability, shakiness, or headache with missed meal, relieved by food

__ Craving for sweets

__ Heart palpitations when you eat something sweet

__ Fatigue one to three hours after eating, especially carbs/sweets

__ Use of caffeine to get energy

__ Mood swings

__ Poor concentration

__ Wakefulness during the night with restlessness and worry

Diabetes

__ Extreme thirst

__ Frequent urination

__ Extreme fatigue

__ Night sweats

__ Overweight

__ Frequent infections including yeast infections

__ Family history of diabetes

__ Slow wound healing

___ Numbness or tingling in hands and/or feet

Section 6: Digestive Imbalance Including Dysbiosis, Yeast (Candida), and Food Sensitivities

___ Use of antibiotics for more than one month at any time in your life

___ Recent use of broad-spectrum antibiotics

___ Digestive problems including bloating and gas

___ Cravings for sweets, alcohol, bread, pasta

___ Recurrent vaginal infections

___ Cystitis, interstitial cystitis, or recurring bladder infections

___ General feeling of being tired all over

___ Poor concentration and memory; feeling spacey at times

___ Sensitivity to perfumes, strong smells, tobacco smoke

___ Headaches

___ Muscle aches

___ Pain or swelling in joints

___ Endometriosis or infertility

Section 7: Toxin Overload

___ Susceptibility to infections

___ Nausea

___ Clumsiness

___ Frequent irritability and anger

___ Memory loss, which may be intermittent

___ Irregular heartbeat

___ Dizziness

___ Headaches

___ Tinnitus (ringing in the ears)

___ Numerous food allergies and/or sensitivities

___ Unexplained fatigue

Section 8: Headaches, Arthritis, and Osteoporosis

___ Generalized aches or stiffness

___ Stiff, painful, or swollen joints

___ Easy fracture; i.e., brittle bones

___ Muscle spasms or cramps

___ Leg cramps at night

___ Back pain

___ Bursitis or tendinitis

___ Neck and shoulder pain

__ Extreme fatigue

Now let’s look at your results.

If you’ve noted three or more symptoms in one category, you can go to the appropriate chapter for more information. It will give you some more clues about the direction you’ll need to take to regain your health. Then you will create your action plan based on what you’ve discovered. This will include food, supplements, activities, and further investigation, including lab tests.

Make a note of the imbalances you are further investigating in your journal entries for Week 2. Here are topics to address:

1. Category or categories in which I checked three items or more on the questionnaire:

2. After reading the relevant chapters, these are my insights and thoughts:

3. Based on my newfound information and my intuition, my major imbalance is:

4. The reasons I think this are:

From 8 Weeks to Vibrant Health: A Take Charge Plan for Women by Dr. Hyla Cass and Kathleen Barnes (Take Charge Books, 2008).

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The content provided by this site is for informational purposes only and has not been approved by the U.S. FDA. This site is not intended to provide personal medical advice, which should be obtained from a medical professional.

8 WEEKS TO VIBRANT HEALTH