Transformations' Wellness Operating System Questionnaire Health conditions can sabotage your weight loss, such as; yeast infection, liver, gallbladder and kidney problems, thyroid dysfunction, food allergies, biochemical and emotional imbalances, and others. This test can identify your individual weight loss challenges so your practitioner can support your body’s weak links. Date: March 10, 2010   Phone: First Name:   Email: Last Name:   Last 4 Digits of SSN: Please be thoughtful and thorough in answering these questions, as they are very important. Your answers can greatly assist your Health Care Practitioner in successfully recognizing key nutrient support issues, which may be essential to your successfully losing weight and keeping it off for life, as well as your long term health and well-being. Thank you for your thoughtfulness. Choose the number on the blank which best describes the frequency, or severity of your symptoms. If you do not know the answer to the question, or if the question does not apply, leave it blank. When you are finished, please click Save. The score for YES is 3 and the score for NO is 0. (0) never or rarely (1) twice a week or less (mild) (2) three to six times a week (moderate) (3) daily (severe)   SECTION 1 Part 1-A 0 1 2 3 Indigestion - do you experience regurgitation? Excessive burping, belching and/or bloating following meals? Stomach spasms and cramping during or after eating? A sensation that food sits in your stomach after eating? Abdominal pain on the right side, underneath rib cage? Offensive breath? Diarrhea? Constipation? Alternating diarrhea and constipation? Belching / burping? Excessive bloating or passing of gas? Stomach pains? Acid or spicy foods upset stomach or digestion? Sour stomach frequently? Indigestion soon after meals? Stomach pains before, and/or after meals? Black stools even though not taking iron supplements or bismuth (Pepto Bismol)? Roughage and fiber causes constipation or indigestion? Poorly formed stools? Stools shiny, and/or float? Pain on left side or abdomen, underneath rib cage? Stool - greasy, shiny? Stool yellowish, foul smelling? Undigested food in your stool? When massaging under your rib cage on your left side, there is pain, tenderness or soreness? Dependency on antacids? N(0) Y(3)   Part 1-B 0 1 2 3 Discomfort, pain or cramps in your lower abdominal area? Anal itching? Stool is small, hard and dry? Pass mucus in stool? Rectal pain, itching or cramping? No urge to have a bowel movement? Almost continual need to have bowel movement? Alternating constipation/diarrhea? Prone to vaginal yeast infections? Stomach pain, burning and/or aching over a period of 1-4 hours after eating? Stomach pain, burning/aching relieved by eating food or drinking beverages? Burning sensation in the lower part of your chest, especially when lying down or bending forward? Feel a sense of nausea or desire to vomit when you eat? Indigestion, fullness or tension in your abdomen is delayed, occurring 2-4 hours after eating a meal? Lower abdominal discomfort is relieved with the passage of gas or with a bowel movement? Stool odor is embarrassing? Black, tarry stools? Bloated? Extremely narrow stools, thin stool? Rectal (anal) itching? Three or more large bowel movements daily? Bowel movement shortly after eating (within 1 hour)? History or antibiotic use? N(0) Y(3)   Part 1-C 0 1 2 3 Inflamed corners of mouth? Thirsty often? Feel thirsty, even after drinking water? Weird/strange cravings? Sense of taste seems reduced? Sense of smell seems reduced? How often do you eat 5 servings of fruits and vegetables per day? Cuts heal slowly? Feel depressed, exhausted? Dry skin or scalp? General feeling of poor health? Vegetarian (no eggs, dairy)? N(0) Y(3) Picky eater? N(0) Y(3) Spots on nails? N(0) Y(3) Thick, coarse hairs on body? N(0) Y(3) Consume lots of sweets? N(0) Y(3) Thinning eyebrows? N(0) Y(3) Most foods you eat come in a box or can? N(0) Y(3) Diet is low in fiber? N(0) Y(3)   Part 1-D 0 1 2 3 Frequently experience confusion? N(0) Y(3) Poor memory? N(0) Y(3) Seem overly sensitive to noise? N(0) Y(3) Decreased sense of smell? N(0) Y(3) Irritable? N(0) Y(3) Tendency to nightmares? N(0) Y(3) Long standing tendency to depression? N(0) Y(3) Feel apathetic? N(0) Y(3) Tendency to anxiety? N(0) Y(3) Feeling of impending doom? N(0) Y(3) History of hypothyroidism? N(0) Y(3) Tendency to hyperactivity? N(0) Y(3) History of chronic headaches? N(0) Y(3) Frequent nervousness? N(0) Y(3) Inability to concentrate? N(0) Y(3) Learning problems? N(0) Y(3) Frequent or long standing fatigue? N(0) Y(3) Restlessness? N(0) Y(3) Low tolerance to stress? N(0) Y(3) History of insulin sensitivity? N(0) Y(3) History of high cholesterol? N(0) Y(3) History of high homocysteine levels? N(0) Y(3) History of asthma? N(0) Y(3) Muscular weakness? N(0) Y(3) Irregular heart rhythms? N(0) Y(3) Tendency to anemia? N(0) Y(3) Hair loss? N(0) Y(3) Poor circulation? N(0) Y(3) Chronic constipation? N(0) Y(3) Tendency to edema (water retention)? N(0) Y(3) Tendency to nausea? N(0) Y(3) History of glaucoma? N(0) Y(3) Tendency towards warts or skin tags? N(0) Y(3)   SECTION 2 Part 2-A 0 1 2 3 When massaging under your rib cage on your right side, there is pain, tenderness or soreness? Flushing, or "hot flashes", shortly after you eat? How often do you experience right shoulder/neck pain? Feel like you have the "flu"? Belch up bitter fluid after eating? Feel abdominal discomfort or nausea when eating fatty or fried foods? Unexplained itchy skin, that may be worse at night? Stool color alternates from clay colored to normal brown? General feeling of poor health? Easily bruise? More than 10 beers, or 10 ounces or alcohol, per week? Drink caffeinated beverages? Sensitive to even small amounts of alcohol? Personal or family history of cancer? Sensitive to fragrances, exhaust fumes, or strong odors? Abdominal pain on right side? Use artificial sweeteners regularly? Exposed to chemicals or radiation at work or in home? How often do you use cosmetics/make-up? How often do you experience fatigue or sluggishness? How often do you experience apathy or fatigue? How often do you experience hyperactivity or racing thoughts? How often do you experience restlessness? How often do you experience headaches or migraines? How often do you experience poor memory? How often do you experience confusion? How often do you experience poor concentration, and/or coordination? Have you ever been diagnosed with multiple chemical sensitivity? N(0) Y(3) Have you ever been diagnosed with Fibromyalgia, Chronic Fatigue, Gulf War Syndrome? N(0) Y(3) Yellowish tint to white part of eyes? N(0) Y(3) Yellowish tint to skin? N(0) Y(3) Personal or family history of Parkinson's, Alzheimer's or other neurological diseases? N(0) Y(3) Personal or family history of lupus, rheumatoid arthritis, multiple sclerosis, ankylosing spondylitis or other autoimmune disease? N(0) Y(3) Do you feel poorly after consuming grapefruit/grapefruit juice? N(0) Y(3)   SECTION 3 Part 3-A 0 1 2 3 Upper eyelids look swollen? Feel chilled? Have difficulty getting "going" in the morning? Hands and feet feel cold? Slow, sluggish speech? Voice get coarse or hoarse? Swelling, or dark circles, around eyes? Constipation? High cholesterol or blood lipids? Periods that are irregular (too heavy or too light)? Breast pain, and/or fibrocystic breast disease? Feel fatigued, exhausted? Weight gain or difficulty losing weight? Water retention? Frequent infections? Muscle weakness, cramps or pains? Ligaments are lax? Slow, weak heart rate? Congestive heart failure? Skin, and/or hair dry/coarse? Slow wound healing? Thick, brittle nails with ridges? N(0) Y(3) Hair loss? N(0) Y(3) Loss of eyebrow hair? N(0) Y(3) History of multiple miscarriages? N(0) Y(3) Infertility? N(0) Y(3) PMS type symptoms? N(0) Y(3) Menstrual cramps? N(0) Y(3) Tongue is thick with ridges? N(0) Y(3) Carpal tunnel syndrome or other nerve compression? N(0) Y(3)   Part 3-B 0 1 2 3 Wounds heal slowly? Your body - or parts of your body - feel tender, sore, sensitive to the touch, hot and/or painful? Brown spots on face? Lack of exposure to full-spectrum natural light on a daily basis for at least 15 minutes? Thin, and/or dry skin? Unstable blood sugar? Physical intolerance to exercise? Feelings of greying out or blacking out? Chronic fatigue; not relieved by sleep? Feelings of heart racing when rising rapidly from a sitting or lying position? Difficulty getting up in the morning (don't really wake up until about 10:00 am)? Experience chronic fatigue? Tenderness in my back near my spine at the bottom of my rib cage, when pressed? Need coffee or some other stimulant to get going in the morning? Crave salt and/or foods high in salt? Crave high protein foods (meats, cheeses, etc.)? Feel better if I lie down? Experience light, non-restful sleep? Feel anxiety? Pre-mature greying of hair? Best, most refreshing sleep often comes between 7:00 am and 9:00 am? N(0) Y(3) Low blood pressure? N(0) Y(3) Spinal curvature, and/or scoliosis? N(0) Y(3) Overwork with little play or relaxation for extended periods? N(0) Y(3) Tend to gain weight, especially around the middle (spare tire)? N(0) Y(3) Get light-headed or dizzy when rising rapidly from a sitting or lying position? N(0) Y(3) Experience constant stress in my life or work? N(0) Y(3) I suffer, or have suffered, from nervous breakdowns? N(0) Y(3) My relationships at work and/or home are unhappy? N(0) Y(3) Type A personality? N(0) Y(3) My best work is late at night (or early morning hours)? N(0) Y(3)   Part 3-C 0 1 2 3 Decrease or loss of muscle tone? High cholesterol or triglycerides? Bone loss (Osteopenia or Osteoporosis)? Loss of hair? Sagging skin, loss of skin elasticity? Feel pessimistic, like things won't or don't go right? Wounds heal slowly? Weak immune system, frequent infections? Decreased sexual function, ability or desire? Excess abdominal fat ("spare tire")? Decreased energy, especially in the morning? Depression, especially in the morning? Poor metabolism, weight gain? N(0) Y(3)   Part 3-D 0 1 2 3 Increased thirst? Nightmares, possibly associated with going to bed on an empty stomach? Unusual thirst - feeling like you can't drink enough water? Polycystic ovary syndrome? (Women only) Headaches that are relieved by eating sweets or alcohol? Irritable is meals missed? Crave sweets, often? Hungry, even shortly after you eat? Suffer from poor memory or concentration when skip meals? Feel tired, or hungry, and hour or so after eating? Feel shaky when miss meals? Afternoon fatigue? Suffer from mood swings, and/or depression when meals are missed? Anxious if meals skipped? Desire to lose weight? Clothes don't fit anymore? N(0) Y(3) Have diabetes or borderline diabetic? N(0) Y(3) Eat snacks frequently? N(0) Y(3) Family history of diabetes? N(0) Y(3) Tend to gain weight around middle "Spare tire"? N(0) Y(3) Overweight? N(0) Y(3)   SECTION 4 Part 4-A 0 1 2 3 Prone to lots of phlegm or mucus associated with seasonal changes? Puffiness, and/or dark circles under eyes? Migraine headaches? Hyperactivity? Chinese food causes anxiety, irregular heart beat or fatigue? Sneeze more than 3 times after meals or drinks? Pulse "speeds" after meals? Prone to lots of phlegm or mucus associated with certain foods? Joint, and/or muscle pain, stiffness or achyness? Stomach, and/or intestinal disturbances? N(0) Y(3)   SECTION 5 Part 5-A 0 1 2 3 Poor wound healing? Fatigue? Blood sugar imbalances/hypoglycemia? Tendency towards, or presence of, anemia? Feel tired, fatigued? Shortness of breath? Feels like heart races? Depression? Skin ulcers of the legs or feet? Varicose or "spider" veins? Nose bleeds frequent? Bruise easily, "black/blue" spots? Noises in head or "ringing in ears"? One leg or arm - shiny hairless skin?   Part 5-B 0 1 2 3 Pain in big toe? Pain in joints? Stiffness in joints lasting more than 30 minutes on arising in mornings? Stiffness in joints lasting more than 30 minutes after pro-longed activity? Deformed joints? Redness, and/or heat in joints? Chronic pain or stiffness? Pain in muscles? Muscle cramps or spasms? Muscle twitch or tremor - eyelids, thumb, calf-muscle? Irresistible urge to move legs often? Muscles stuff, sore, tense, and/or ache? Feel "tense" in body? Legs move during sleep? Stomach or intestinal disturbances? N(0) Y(3)   SECTION 6 Part 6-A 0 1 2 3 Elevated blood cholesterol? N(0) Y(3) High triglyceride levels? N(0) Y(3) Low HDL levels? N(0) Y(3) Overweight? N(0) Y(3) Lack of social support of fulfillment? N(0) Y(3) History of diabetes? N(0) Y(3)   Part 6-B 0 1 2 3 Exhaustion with minor exertion? Difficulty catching breath, especially during exercise? Cold feet and/or toes appear blue? When standing, legs get heavy and fatigued? Leg discomfort or fatigue relieved by elevating legs? Swollen ankles, worse at night? Temper - "fuse" - short? Dull pain in chest or radiating into left arm, worse with activity or excitement? Smoker? N(0) Y(3) Overweight? N(0) Y(3) Type A personality? N(0) Y(3) High blood pressure (Hypertension)? N(0) Y(3) Muscle cramps when active? N(0) Y(3)   SECTION 7 Part 7-A 0 1 2 3 Blood in urine or cloudy urine? Strong, foul smelling urine? Pain in back, at base of ribcage (one or both sides)? Feel like you have the "flu"? Pain or burning during urination? Cloudy urine? Dark urine? Kidney stones? N(0) Y(3)   Please answer yes or no to the following questions: 1. Are you now taking, or have taken in the past, Thyroid medication? N(0) Y(3) 2. Are you now taking, or have taken in the past, Blood pressure or Cholesterol medication? N(0) Y(3) 3. Have you been diagnosed as diabetic or Borderline diabetic? N(0) Y(3) 4. Have you ever had a seizure? N(0) Y(3) 5. Have you ever been diagnosed with Gout, Kidney, Liver or Heart disease? N(0) Y(3) 6. Do you react to milk product - now or in the past? N(0) Y(3)   Please list below the 5 most important health concerns or complaints you presently have, in order of importance. 1. 2. 3. 4. 5.
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