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Client's Name: *

Client's Phone: *

Client's Email: *

Today's Date:

Age:

Height:

Weight:

Street Address:

City, State, Zip:

Counselor/Manager: *

Facility Phone: *

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Test One: Carbohydrate Sensitivity

Check off each symptom that occurs with any degree of regularity

Nervousness

Irritability

Fatigue & Exhaustion

Faintness, dizziness, cold sweats,
shakiness, weak spells

Depression

Drowsiness, especially after meals or in mid-afternoon

Headaches

Digestive disturbances with
no obvious cause

Forgetfulness

Insomnia

Needless worrying

Mental Confusion

Rapid pulse, especially after
eating certain foods

Muscle pain

Antisocial behavior

Over-emotional, crying spells

Lack of sex drive

Leg cramps

Blurred Vision

Shortness of breath, sighing
and excess yawning

Cravings for starch and sugar-rich foods

Please list any medications you are currently
taking AND the condition for which you take them:

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Test Two: Calorie Sensitive Test

Check off each statement that most accurately applies to you

You had a normal body weight when younger, but slowly gained weight after age 30.

You are presently overweight but by 25 pounds or less..

You have a normal appetite. (get hungry at mealtimes).

You have few, if any food cravings

You have maintained the same basic eating habits all your life.

You eat three meals a day.

You have gained a certain amount of extra body weight but seem to have tapered off
(not continued to steadily gain more and more weight).

You have few or none of the symptoms associated with poor
carbohydrate metabolism as discussed in test one.

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Test Three: Carbohydrate Intolerant Test

Check off each statement that most accurately applies to you

You are more than 25 pounds overweight

You have had a tendency to be overweight all your adult life.

You have been overweight since you were younger.

You have a poor appetite and skip meals often

You prefer not to eat in the morning.

You have food cravings that temporarily go away when
starchy or sugary foods are eaten.

There are foods that you feel you could absolutely not do without.

Your waist is bigger than your hips (men).

Your waist is more than twice the size of your hips ( women).

Most or all of the symptoms associated with carbohydrate intolerance
and/or excess stress on "Test One" apply to you.

Are you, or have you in the past year,
taken any of the following classes of medications?

Thiazide Diuretics

Steroids (ie.prednisone or cortisone)

Epinephrine containing medications

Anti-depression drugs

Statin (cholesterol) medications

Beta-Blockers

Birth Control Pills

Anti-anxiety drugs

Diabetes medications

Diet pills containing caffeine

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Test Four: Insulin Profile

Provide the answer where indicated

Do you Exercise? Yes No

If yes, how often? What type?

Do you consume Diet Soft Drinks? Yes No

Do you consume Alcoholic Beverages? Yes No

How Many?

Do you use Artificial Sweetner? Yes No

Do you consume coffee? Yes No

How many meals do you consume daily?

Do you snack between meals? Yes No

Do you have any food cravings? Yes No

Please list in order of craving intensity:

Do you have now or have you ever had any of the following:

Frequent cravings for sweet or salty, crunchy snack foods

Difficulty losing weight even if you exercise or cut back on your foods

Difficult with weight gain even when eating small amounts of food

Weight gain mostly around your waist

Skin tags (small, painless, floppy skin growths)

High triglyceride

Low HDL (good) cholesterol

High LDL (bad) cholesterol

Afternoon Fatigue

High uric acid or gout

Native-American, Asian, African-American, Pacific Islander or Hispanic Ancestry

Family history of type II diabetes or hypoglycemia.
If checked, list family members:

Please list any dietary supplements you are currently taking:

Please list any diet programs you have followed in the past
and the results you have obtained from them.

If you have failed at weight loss programs in the past,
please describe why you feel you were not successful.

Comments: (provide any additional information you feel may be helpful to us).

Please check off any, in each group, that apply:

Do you suffer from any of the following:

Severe Carbohydrate Intolerance

Diabetes

Hypoglycemia

PCOS

Excess Stress

Under Active Thyroid or other glandular problems

Menopause Symptoms

Candida or Systemic Yeast Problems

Do you or have you taken Birth Control Drugs

Arthritis / Chronic Inflamation
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