UPDATE FORM Name What positive changes have you noticed since your last appointment? What are your main concerns at this time? Any changes with weight and/or waist size? How is your sleep? Constipation or diarrhea? Gas or bloating? Which? How is your mood? Is your energy level higher or lower lately? To what do you attribute this energy level? Are you in any pain on a regular basis? Please describe. If this is ongoing pain, is it better, same, or worse than before? Are you receiving good support from those around you for the changes you are making? Are you taking all supplements consistently? Any concerns? What do you see as a significant barrier to you making more/faster progress toward your health goals? Are you cooking more? What are you doing or feeling when you crave? What's your food like these days?Breakfast Lunch Dinner Snack Liquids Symptom QuestionnairePlease use this scale to rate the frequency and severity of symptoms you have experienced over the past two weeks. If multiple choices are given, please specify what applies in the comment column. 0 - Never have the symptom. 1 - Occasionally have it and the effect is mild. 2 - Occasionally have it and the effect is severe. 3 - Frequently or Consistently have it and the effect is Mild 4 - Frequently or Consistently have it and the effect is Severe HeadacheScoreComments or Details, if applicable. FaintnessScoreComments or Details, if applicable. DizzinessScoreComments or Details, if applicable. InsomniaScoreComments or Details, if applicable. Stuffy noseScoreComments or Details, if applicable. Sinus problemsScoreComments or Details, if applicable. Hay feverScoreComments or Details, if applicable. Sneezing attacksScoreComments or Details, if applicable. Excessive mucus formationScoreComments or Details, if applicable. Chronic coughingScoreComments or Details, if applicable. Gagging or frequent need to clear throatScoreComments or Details, if applicable. Sore throat, hoarseness, or loss of voiceScoreComments or Details, if applicable. Swollen or discolored tongue, gums, or lipsScoreComments or Details, if applicable. Chronic tooth or gum pain or jaw pain. Which?ScoreComments or Details, if applicable. Canker soresScoreComments or Details, if applicable. AcneScoreComments or Details, if applicable. Hives or other allergic breakoutScoreComments or Details, if applicable. Rash or persistently dry skinScoreComments or Details, if applicable. Hair lossScoreComments or Details, if applicable. Flushing or hot flashesScoreComments or Details, if applicable. Frequently feel coldScoreComments or Details, if applicable. Excessive sweatingScoreComments or Details, if applicable. Part of body frequently feeling numb. Which?ScoreComments or Details, if applicable. Irregular or skipped heartbeatScoreComments or Details, if applicable. Rapid or pounding heartbeatScoreComments or Details, if applicable. Chest painScoreComments or Details, if applicable. Chest congestionScoreComments or Details, if applicable. Asthma, bronchitisScoreComments or Details, if applicable. Shortness of breathScoreComments or Details, if applicable. Difficulty breathingScoreComments or Details, if applicable. Nausea or vomitingScoreComments or Details, if applicable. DiarrheaScoreComments or Details, if applicable. ConstipationScoreComments or Details, if applicable. Bloated feelingScoreComments or Details, if applicable. Belching, burpingScoreComments or Details, if applicable. Passing gas, flatulenceScoreComments or Details, if applicable. HeartburnScoreComments or Details, if applicable. Intestinal or Stomach pain. Which?ScoreComments or Details, if applicable. Other pain in GI tract? Where?ScoreComments or Details, if applicable. Pain or aches in jointsScoreComments or Details, if applicable. ArthritisScoreComments or Details, if applicable. Stiffness or limitation of movementScoreComments or Details, if applicable. Pain or aches in musclesScoreComments or Details, if applicable. Tremor or restless legScoreComments or Details, if applicable. Feeling of weakness or tirednessScoreComments or Details, if applicable. Binge eating/drinkingScoreComments or Details, if applicable. Craving certain foodsScoreComments or Details, if applicable. Excessive weightScoreComments or Details, if applicable. Compulsive eatingScoreComments or Details, if applicable. Water retentionScoreComments or Details, if applicable. UnderweightScoreComments or Details, if applicable. Fatigue, sluggishnessScoreComments or Details, if applicable. Apathy, lethargyScoreComments or Details, if applicable. HyperactivityScoreComments or Details, if applicable. RestlessnessScoreComments or Details, if applicable. Poor memoryScoreComments or Details, if applicable. Confusion, poor comprehensionScoreComments or Details, if applicable. Poor concentration or focusScoreComments or Details, if applicable. Poor physical coordinationScoreComments or Details, if applicable. Difficulty in making decisionsScoreComments or Details, if applicable. Stuttering or stammeringScoreComments or Details, if applicable. Learning disabilitiesScoreComments or Details, if applicable. Mood swingsScoreComments or Details, if applicable. Anxiety, fear, nervousnessScoreComments or Details, if applicable. Anger, irritability, aggressivenessScoreComments or Details, if applicable. DepressionScoreComments or Details, if applicable. Other mood challenges?ScoreComments or Details, if applicable. Frequent illnessScoreComments or Details, if applicable. Frequent or urgent urinationScoreComments or Details, if applicable. Inability to urinate or low urine flowScoreComments or Details, if applicable. Low libido or other sexual dysfunctionScoreComments or Details, if applicable. Genital itch or dischargeScoreComments or Details, if applicable. Women: Breast fibroidsScoreComments or Details, if applicable. Women: Painful or tender breastsScoreComments or Details, if applicable. Women: Uterine fibroidsScoreComments or Details, if applicable. OtherScoreComments or Details, if applicable. OtherScoreComments or Details, if applicable.