Questionnaire to Assess:  Thin Myelin, Adrenal and Liver
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Your Name:

Your Name:


Email

Email


Confirm Email

Confirm Email


Birth date of patient DD/MM/Year

Birth date of patient DD/MM/Year


Name of person this questionnaire is about (write same if it is you):

Name of person this questionnaire is about (write same if it is you):


Sex of person whose information is on this questionnaire?

Sex of person whose information is on this questionnaire?

Do you want to be contacted with a protocol suggestion?

Do you want to be contacted with a protocol suggestion?

Some people just are curious and we support that, only those who request will be sent and email with suggestions.   Please note there is no charge for this service.
Are you submitting this questionnaire in behalf of someone else?

Are you submitting this questionnaire in behalf of someone else?

If so whom?
Which medications, if any, that you currently take have restrictions?

Which medications, if any, that you currently take have restrictions?


SYMPTOMS OF A THIN MYELIN

SYMPTOMS OF A THIN MYELIN

Does noise, people or commotion get on your nerves?
How often do you have dreams (no nightmares)?
Do you hear voices or sounds which are not there?
Do you try to avoid large groups of people or noisy places?
Do you have a hard time concentrating when things are going on around you?
Do you have invasive thoughts?
Do you play the radio, TV, fan or air conditioner (white noise) to help you sleep better or help you fall to sleep?
Does sudden noises startle you?
Do you have rituals that you need to do to feel you did something right?
Do you tend to turn things off or down when someone is talking to you?
Have you had the sensation that someone has touched you or is sitting or standing next to you but no one is there?
Do you ever think you see someone or something out of the corner of your eye but when you turn your head, nothing is there?
Do you forget where you are or what direction a place is that you have gone to often?
Do you forget common words or names?
Do you have a hard time getting a song out of your head?
Do you feel compelled to say your prayers over and over again, fearing you have not said them right?
SYMPTOMS OF A WEAK OR TOXIC LIVER

SYMPTOMS OF A WEAK OR TOXIC LIVER

How often do you have bowel movements?
Do you get night sweats?
Do the muscles in the shoulder/neck area get tight?
Do feel bloated after you eat?
Do you have flatulence (passing gas) more than 1 time a week?
Do you have poor night vision?
Symptoms that the liver is not balancing blood sugar levels include: getting either shaky, weak, grouchy or aggressive. If you skip a meal do you experience any of the above? Or have you been diagnosed as having hypoglycemia?
Do you have diabetes or feel like taking a nap after you have eaten a large meal?
Do you wake up at night (to urinate or fluff the pillows or look at the clock, etc.) between 1 and 5 and then go back to sleep?
Do you have or have you ever had psoriasis, eczema, boils or acne?
Do you have or have you ever had moles or skin tags?
If female, do you have or have you ever had heavy or clotty, frequent or missed menses (periods or menstruation), or endometriosis? If male, mark never
If female, have you had fibroids, tumor in breast or uterus? If male, mark never
If female, do you have or have you ever had mood swings, PMS, or menopausal problems? If male, mark never
If female, do you have or have you ever had cysts on your ovaries? If male, mark never
Have you ever had hot flashes?
If male, have you ever had a high PSA or swollen prostate (including prostate cancer)? If female, mark never
What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol

What is your HDL (High Density Lipoprotein) aka your GOOD cholesterol


What is your total cholesterol number?

What is your total cholesterol number?


Are you on cholesterol medicine?

Are you on cholesterol medicine?


Have you ever had hepatitis or cirrhosis of the liver?

Have you ever had hepatitis or cirrhosis of the liver?


What is your triglyceride number?

What is your triglyceride number?


ADRENAL SYMPTOMS

ADRENAL SYMPTOMS

Do you experience mood swings and/or depression?
Do you now or have you ever had LOW blood pressure?
Do you know or have you ever had HIGH blood pressure?
Does your skin get dark where clothes or skin rubs (for instance around the pant waist band or bra or inner thigh)?
Do you have a hard time getting to bed early AND do you have a hard time awakening early in the morning?
Do you have an energy dip around 2 to 3 pm and then get your second wind later on?
Are you on any medication which has diet or supplement restrictions?

Are you on SSRI's?

OTHER REMARKS

OTHER REMARKS

Do you have anything else that you feel is important to add?

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