Inflammation Questionnaire

What has recently changed in your health that has prompted you to fill out this questionnaire?

1.Are you forgetful, struggle finding words, have brain fog, have a difficult time concentrating, misplace things, or feel more anxious more than usual?

2. Do you feel more depressed for with no identifiable reason? Do you feel you have lost motivation/interest in the things you used to find joy?

3. Do you experience bloating, gas, diarrhea, constipation, or heartburn after eating?

4.Do you struggle with chronic bad breath despite good oral hygeine?

5. Does your weight fluctuate more than 5 pounds in a day or do you feel like your body is larger on some days and smaller/tighter on other days unrelated to fat loss/gain?

6. Do you have unexplained itching flaking or rashes on your hands or feet?

7. Do you experience pain or tenderness in the upper right abdomen that is unrelated to eating?

8. Do you struggle with cravings for sugar/starchy foods even when you have already eaten or feel full (in between meals and after a big meal)?

8. Do you struggle losing weight despite calorie restriction and exercising?

9. Do you experience cold hands or feet even in a warm environment?

10. Do you experience afternoon fatigue, but get a "second wind" before bed causing you to stay awake?

11. Women: Do you expericene irregular periods, painful or heavy periods or changes to libido?

Men: Have you experienced changes in libido or sexual performance such as erectile dysfunction?

12. Do you experience joint pain that comes and goes, or is unrelated to injury?

13. Do you experience pins and needles or tingling sensation in your hands, feet or in your extremities?

14. Do you or anyone in your family have a history of autoimmune conditions like hashimotos, rheumatoid arthritis, lupus, irritable bowel disease, multiple sclerosis?

15. How comited are you to making changes to diet, and lifestyle to improve your health?

What is your timeline for feeling better?

Do you wish to be contacted by Halo Health and Wellness to discuss your questionnaire results?