Clinical Assessment Form

Full Name *

Email *

Date *

Instructions

Rate each of the questions to the best of your ability based on your experiences over the past 90 days. Please take note of your scores for each question. Total your score in the space provided at the end of each section and compare your results with the rating system.

Mitochondrial Dysfunction

History of infections (EBV, Lyme, etc.)?

Dizziness upon standing up quickly

Unable to tolerate much exercise

Poor exercise or muscle stamina

Low muscle tone?

Brain fog

Difficulty focusing

Vision or hearing problems

General or chronic fatigue

Afternoon headaches

Migraines or seizures

Mood problems: anxiety, depression, or bipolar

Poor brain processing (cognition)

Blood sugar issues

Breathing problems

Overweight?

Low body temperature

Intolerant to heat

Low thyroid lab numbers?

Little or no skin sweating?

Suppressed immune system?

Catch colds or get sick easily?

Chronic inflammation

Cannot fall asleep

Cannot stay asleep

Slow mover in the morning (hard to get going)

Wake up tired, even after 6 or more hours of sleep

Eyes sensitive to bright or direct light

Weight gain when under stress

Loss of libido

Mitochondrial Dysfunction Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Drainage Dysfunction Susceptibility

Constipation (pooping one or fewer times daily)

Feeling that bowels do not empty completely

General and/or chronic fatigue

Persistent inflammation

Wake up between 1 a.m. to 4 a.m.

Edema, swelling or retain extra fluids

Skin problems, rashes, itches, hives, eczema, or acne

Yellowish skin, face

Weakened immune system

Can't clear infections, despite following pathogen protocols

Sore or swollen breast tissue

Heart palpitations or irregular heartbeat

Light, sound, or EMF sensitivities

Morning stiffness

Cognitive fog

Swollen glands

Cellulite or flabby skin

Varicose or spider veins

Kidney problems

Breathing or lung issues

Skin doesn't sweat

Puffy Eyes

Drainage Dysfunction Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Minerals & Electrolytes

Edema (swelling) in ankles or wrists

Muscle cramping

Poor muscle endurance

Frequent urination

Frequent thirst

Crave salt

Unable to hold breath for long periods

Shallow, rapid breathing

History of carpal tunnel syndrome

History of lower right abdominal pains or ileocecal valve problems

History of stress fracture

Bone loss (reduced density on bone scan)

Crave chocolate

Feet have a strong odor

History of anemia

Whites of eyes (sclera) are blue-tinted

Hoarse voice

White spots on fingernails

Minerals & Electrolyte Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Blood Sugar

Crave sweets during the day

Irritable if meals are missed

Eating relieves fatigue

Agitated, easily upset, nervous

Fatigue after meals

Must have sweets after meals

Forgetful; poor memory

Feel better or calmer after eating

Prone to infections and colds

History of diabetes in your family

Sugar (glucose) detected in urine test?

Hair loss at ankles/frictional alopecia?

Blood Sugar Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Organs

Stomach

Belching or burping

Gas quickly following a meal

Bad breath

Feel full while eating and after meals

Difficulty digesting fruits and vegetables; undigested food found in stools

Stomach pain, burning, or aching 1 to 4 hours after eating

Temporary relief by using antacids, food, milk, or carbonated beverages

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, or caffeine

Indigestion

Abdominal bloating

Constipation

Diminished appetite

Stomach Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Small Intestine

Increased gut motility, diarrhea

Alternating constipation and diarrhea

Small Intestine Total

Poorly formed or loose stools

Stools have foul odor

Suspect nutrient malabsorption

Diagnosed with celiac disease, irritable bowel syndrome (IBS), or diverticulosis/diverticulitis

Stomach cramps

Flatulence (gas)

Fiber-rich diet doesn’t help constipation

History of pimples or skin eruptions?

Any known food allergies?

Mucus in stool

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Colon

Experiencing a sensation of incomplete bowel emptying.

Lower abdominal pain relieved by passing stool or gas

Experiencing alternating episodes of constipation and diarrhea.

Constipationn

Hard, dry, or small stool

Coated tongue or buildup of debris on tongue

Use laxatives

History of bladder and/or kidney infection

Yeast infection (including vaginal)

Fingernail and/or toenail fungus

Use of antibiotics in past year?

Colon Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Intestinal Permeability

Adverse reactions to foods

Unpredictable food reactions

Aches, pains, and swelling throughout your body

Unpredictable abdominal swelling

Food allergies

Frequent bloating and distention after eating

Leaky Gut Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Hypothyroid

Tired or sluggish

Feel cold (hands, feet, or your whole body)

Require an excessive amount of sleep to function properly

Gain weight easily

Difficult, infrequent bowel movements

Depression or lack of motivation

Thinning of outer third of eyebrows

Thinning of hair on scalp, face, or genitals, or excessive hair loss

Dry skin and/or scalp

Slow brain processing

Lack of or diminished sex drive

Heavy or profuse menstrual bleeding (women only)

Infertility and/or impotency

Hypothyroid Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Hyperthyroid

Heart palpitations

Inward trembling

Increased pulse, even at rest

Nervous or emotional

Insomnia

Night sweats

Eyes appear bulging or swollen

Difficulty gaining weight

Hyperthyroid Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Pathogens

Parasites

Restless sleep (toss, turn, or wake up often)

Skin issues, rashes, itches, hives, eczema, or acne

Frequent diarrhea or loose stools

Experiencing fluctuating episodes of constipation followed by diarrhea

SIBO (small intestinal bacterial overgrowth), feel bloated or gassy

Bowel urgency, occasional accidents

Abdominal pains, cramps, or burning

Rectal, anal itch

Anal fissures (small, painful tears or cracks)

Stomach or small intestinal ulcers or lesions

Grinding of teeth when asleep

Picking at nose, boring nose with finger

Excess boogers in nose and scab-like boogers

Fingernail biting

Headaches/Migraines

Irritable (no apparent reason)

Mood disorder, depression, anxiety, or suicidal thoughts

Hyperactive tendency (nervous)

Dark circles under eyes

Need for extra sleep, wake unrefreshed

Allergies and/or food sensitivities

Fevers of unknown origin

Night sweats (not menopausal)

Kiss pets, allow pets to lick your face

Increase of symptoms around a full moon

Anemia (low iron/hemoglobin on blood test)

Iron deficiency

Vitamin B6 deficiency

Zinc deficiency and/or white spots on nails

Frequent colds, flu, sore throats

Travel in developing nations

Eat pork products

Eat sushi, raw fish

Sleep with pets on bed

Bed-wetting

Frequent vomiting

Loss of appetite

Hungry all the time, bottomless pit, hungry after meals

Strong sugar and processed food cravings

Breathing problems, asthma

Pain in belly button area (umbilicus)

Blurry, unclear vision

Eye floaters

Lethargy, apathy (disinterest)

Menstrual problems

Dry lips

Drooling while asleep

Occult blood in stool (from lab test)

Swim in creeks, rivers, lakes

History of Giardia, pinworms, or other parasites?

Parasite Total

History of or currently have cancer?

Are you employed in the field of childcare?

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

SIBO (Small Intestinal Bacterial Overgrowth)

Abdominal distention after consuming fiber, starches, or sugar

Abdominal distention after taking certain probiotics or other dietary supplements

Abdominal distention, bloating, or a noisy gut after eating healthy vegetables

Bloating or feeling full in upper abdominal area (just below rib cage)

SIBO Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Lyme Disease Risks

Ever diagnosed with Lyme disease?

Dry sockets or infected tooth extractions

Ever bitten by a tick?

Ever had a bullseye rash on any part of your body?

Mother ever diagnosed with Lyme disease?

Spouse/partner/significant other diagnosed with Lyme disease?

Ever diagnosed with chronic fatigue syndrome, f ibromyalgia, lupus, rheumatoid arthritis (RA), multiple sclerosis (MS), or an autoimmune condition?

Ever diagnosed with Parkinson’s disease, Alzheimer’s disease, or Tourette’s syndrome?

Frequently go camping, hunting, or engage in outdoor activities?

History of a heart murmur or valve prolapse?

Lyme Disease Risks Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Lyme

Arthritis-like joint pain or swelling

Pain migrates or moves around to different areas of your body

Forgetfulness or poor short-term memory

Confusion, difficulty thinking

Disorientation (getting lost; going to wrong places)

Difficulty with speech or writing

Tingling, numbness, burning, or stabbing sensations

Disturbed sleep: too much, too little, early awakening

Unexplained fevers, sweats, chills, or flushing

Unexplained weight change (loss or gain)

Difficulty swallowing

Fatigue, lack of energy

Sore throat or swollen glands

Pelvic or testicular pain

Crepitus (joint cracking)

Stiff neck

Twitching of facial or other muscles

Muscle pain or cramps

Costochondritis (sternum/breastbone and rib junction pain)

Right shoulder pain (AC joint)

Facial paralysis (Bell's palsy)

Unexplained menstrual irregularity

Unexplained breast milk production

Irritable bladder or bladder dysfunction

Sexual dysfunction or low libido

Blurry or double vision

Ear buzzing, ringing, or pain

Vertigo or increased motion sickness

Light-headedness, poor balance, difficulty walking

Woozy (mentally unclear or hazy)

Tremors

Headaches

Impulsivity, aggression, or bipolar

Depression

Hallucinations, paranoia, or schizophrenia

Panic attacks

Eating disorder

Pulse skips

Skin hypersensitivity

Gastrointestinal problems

Change in bowel function

Lyme Disease Current Symptoms Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Babesia

Abdominal pain

Shortness of breath

Air hunger (episodes of breathlessness)

Anemia (low iron- hemoglobin on blood test)

Low back stiffness or pain

Low blood sugar

Cough

Disturbed sleep: frequent waking

Excessive sleepiness

Encephalopathy (brain malfunction, brain issues)

Fatigue, tiredness, poor stamina

Fevers

Experiencing headaches

Hemolysis (destruction of red blood cells)

Enlarged liver

Imbalance

Generalized ill feeling

Muscle pains or cramps

Nausea, vomiting

Neck stiffness, pain

Experiencing night sweats

Poor appetite

Shaking chills

Enlarged spleen

Heart palpitations, pulse skips, Tachycardia

Dark urine with or without blood

Weakness

Weight loss

Elevated sedimentation (sed) rate on lab test

Dizziness

Light headedness

Babesia Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Bartonella

Experience abdominal pain

Hematological condition characterized by low levels of iron or hemoglobin detected in blood tests, commonly known as anemia

Anxiety

Back stiffness

Chills

Disturbed sleep: too much, too little, fractionated, early awakening

Ear buzzing, ringing, pain, sound sensitivity

Brain dysfunction

Hemolysis - destruction of red blood cells-

Endocarditis

Myocarditis

Experiencing fatigue, tiredness, and reduced stamina

Low-grade fever

Experience headaches

Liver that has increased in size

Immune deficiency

Feeling of coming down with the flu

Experience insomnia

Jaundice (yellowing of skin)

Joint pain or swelling

Lymph nodes swollen

Overall sense of feeling unwell

Muscle pains or cramps, especially in calves

Foot pain or plantar fasciitis-type pain (heels or soles of the feet)

Stretch mark-like rash (not from overweight)

Maculopapular rash (small red bumps)

Spider veins

Seizures

Sleepiness or drowsiness

Sore throat

Spleen that has increased in size

Shinbone pain

Involuntary shaking or trembling

Twitching of facial muscles

Experiencing weight loss

Eyes: blurred vision, red eyes, dry eyes, depth perception issue, light sensitivity

Anxiety, panic attacks, or excessive worry

Obsessive-compulsive disorder (OCD)

Bartonella Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Toxicants & Toxins

General Toxicity

Live on or near a golf course?

Live near a freeway or high-tension wires?

Wear conventional sunscreen?

Wear perfume or cologne?

Use air fresheners in your house, car, or workplace?

Were you the first-born child?

Receive static shocks (doorknob, car, light switch, other people, etc.)

Headaches or migraines

Word reversal or trouble finding words

Sensitivity to skin or touch

Poor short-term memory

Chronic sinus issues or congestion

Difficulty losing weight regardless of diet or exercise

Excessive perspiring during day or night

Cold extremities (hands and feet)

Issues processing new information

Chronic fungal or viral infection, including Candida, foot fungus, warts, or jock itch

Get sick often

Weakness or numbness in extremities

Joint pain

Muscle cramps, aches, sharp pains

Muscle twitching

Stomach pain

Appetite swings

Rashes or rosacea

General Toxicity Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Radioactive Elements

History of having or currently have cancer?

Compromised immune function

Osteoporosis or osteopenia diagnosis?

Can't clear infections, in spite of following pathogen protocols?

Chronic Candida infection

Fatigue

Anemia*

Skin (red, dry, itchy, color changes)

Hair loss

Loss appetite

Nausea and vomiting

Low blood cell count

Seizures/Convulsions

Earaches or difficulty hearing

Stiff jaw

Sore or dry mouth

Taste changes

Swallowing difficulty

Voice changes, hoarseness

Dry eyes

Stomach ulcers

Tooth decay

Soreness or swelling of the breast

Irregular heartbeat

Heart-palpitations

Radioactive Elements Total

Hormone problems

Bladder infection (cystitis)

Burning or pain during urination

Loss of bladder control

Fertility problems

Sexual problems (male & female)

Problems with kidney

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Mercury Toxicity

Do you have amalgam (silver) fillings in your teeth?

Have you ever had an amalgam removed?

I f you had amalgams removed, was it done by a biological dentist using a safe protocol?

Were there amalgam fillings in your mother's mouth while she was pregnant with you?

Worked in a dental office?

Wore contact lenses during the 1980s or early 1990s

Took oral contraceptives during the 1980s or early 1990s

Have had flu shots

Have had allergy shots

Eat tuna, shark, swordfish or Atlantic salmon more than twice per week

Urinate frequently (during the day, night, or both)

Sleep issues

Do you have compact fluorescent (CFL) bulbs in your home?

Have you broken any CFL bulbs? (reference)

Feelings of anxiety

Mood swings

Anger for no apparent reason

Excessive shyness, timidity, social phobia (not typical to your personality)

Irritability (not typical to your personality)

Dizzy or balance issues

Insomnia (can’t get to sleep or return to sleep)

Low body temperature (below 97.5 degrees Fahrenheit or 36.4 degrees Celsius)

Sound in ears (ringing or hearing your heart beat)

Psychological symptoms, even thoughts of suicide

Sound sensitivities

Mercury Toxicity Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Lead Toxicity

Have lived in a home built before 1978 using lead-based paint

Do home renovation, including sandblasting or moving walls

Currently live or previously lived in a mining community or area

Involved in construction, soldering, metal salvage, or stained glass

Are an electrician, handle electrical devices, electrical wiring, ballasts, or TV glass

Paint or handle/make ceramics, brass, bronze, or crystal

Handle and/or reload ammunition

Read the newspaper regularly before 1985

Previously or currently consume a coral calcium supplement

Wear lipstick

Previously wore or currently wear eye cosmetics containing kohl (a dark pigment that's not FDA-approved for makeup)

Are around or have a lot of fake leather or vinyl

Get your hair colored

Eyelid swelling

Eyelid twitching

Chest or heart pain

Metallic taste in mout

Teeth sensitivity

Bleeding gums

High blood pressure

Inability to decide/indecisiveness

Overwhelmed or fearful feeling

Anemia (low iron - hemoglobin on blood test)

Peeling of top layer of skin (hands, feet)

Dry skin

Feelings of depression

Dyslexia or loss of your place while reading, even as a child

Lead Toxicity Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.

Mycotoxins

See mold growing at home, work, or school?

Ever experienced water damage at home, work, or school?

Home, workplace, or school has a damp or mildewy odor

Spending time in basement causes or worsens symptoms

Basement ever wet?

Symptoms decrease when spend time in a different location for at least a few days?

Plumbing in your kitchen or bathroom leaks or has leaked in the past?

Wet spots anywhere in your home (whether currently or past)?

Often see condensation (fog) on the inside of windows and/or cold surfaces in your home?

Car has a mildewy smell?

Experiencing brain fog

Reactions to supplements opposite of expected

Nosebleeds

Body rashes

Any skin conditions?

Anyone in your home have asthma-like symptoms?

Sinus infections

One or more family members have chronic sinus infections or irritations

Runny, blocked, or stuffy nose

Experience static shocks

Wheezing or whistling in your chest

Wake up in the morning with a feeling of tightness in your chest

Wake up during the night with shortness of breath

Shortness of breath when you're not doing anything strenuous

Wake up during the night with an attack of coughing

Chest tightness when around animals or a dusty part of the house

Achy all over

Having headaches

Extreme or unusual fatigue

Hoarse voice

Memory loss

Difficulty recalling names of people you know

Sensitive to chemicals and smells

Sensitive to EMF's

Bloating or SIBO

Blurry vision

Difficulty sleeping or insomnia

Anxiety or depression

Frequent urination, unable to hold bladder

Mold Total

Results

A score in the yellow or red range suggests this area is more likely a problem for you.