The Super Health Questionnaire
Check 1 circle for any question that is frequently true for you – more than 2-3 times per month.
Check both circles if this is true for you daily or nearly daily.
Answer yes or no where indicated.
If you have more than 2-3 questions marked in any area, this is a problem area that needs attention.
Neurotransmitter Assessment Section:
SECTION A – GENERAL BRAIN FUNCTION
• Is your memory noticeably declining? O O
• Are you having a hard time remembering names
and phone numbers? O O
• Is your ability to focus noticeably declining? O O
• Has it become harder for you to learn things? O O
• Do you have a hard time remembering
your appointments? O O
• Is your temperament getting worse in general? O O
• Are you losing your attention span endurance? O O
• Are you depressed more than usual? O O
• Do you fatigue sooner when driving than in the past?O O
• Do you fatigue when reading sooner than in the past?O O
• Do you walk into rooms and forget why? O O
• Do you pick up your cell phone and forget why? O O
SECTION B – GENERAL BRAIN FUNCTION/STRESS
• Is your stress level high? O O
• Do you always have something that must be done? O O
• Do you feel you never have time for yourself? O O
• Do you feel you are not getting enough sleep or rest? O O
• Do you get regular exercise? O O
• Do you think no one cares about you? O O
• Are you failing to accomplish your life’s purpose? O O
• Do you have no-one to share your problems with? O O
SECTION C – SUGAR BALANCE
SECTION C1 – BLOOD SUGAR FLUCTUATION
• Do you get irritable, shaky, or have lightheadedness
between meals? O O
• Do you feel energized after eating? O O
• Do you have difficulty eating large meals
in the morning? O O
• Does your energy level drop in the afternoon? O O
• Do you crave sugar and sweets in the afternoon? O O
• Do you wake up in the middle of the night? O O
• Do you have difficulty concentrating before eating? O O
• Do you depend on coffee to keep yourself going? O O
• Do you feel agitated, easily upset, and nervous
between meals? O O
SECTION C2 – INSULIN RESISTANCE
• Do you get fatigued after meals? O O
• Do you crave sugar and sweets after meals? O O
• Do you feel you need stimulants such as
coffee after meals? O O
• Do you have difficulty losing weight? O O
• Is your waist girth equal to or larger
than your hip girth? O O
• Do you have frequent urination? O O
• Has your thirst and appetite been increased? O O
• Do you still have sugar cravings after eating sweets?O O
• Do you have weight gain when under stress? O O
• Do you have difficulty falling asleep? O O
SECTION D – SEROTONIN
• Are you losing pleasure in hobbies and interests? O O
• Do you feel overwhelmed with ideas to manage? O O
• Do you have feelings of inner rage (anger)? O O
• Do you have feelings of paranoia? O O
• Do you have feelings of depression? O O
• In general, do you feel like you are not enjoying life? O O
• Do you feel you lack artistic appreciation? O O
• Do you feel depressed in overcast weather? O O
• Are you losing your enthusiasm for your
favorite activities? O O
• Are you losing enjoyment for your favorite foods? O O
• Are you losing your enjoyment of friendships
and relationships? O O
• Do you have difficulty falling into deep restful sleep? O O
• Do you have feeling of dependency on others? O O
• Do you feel more susceptible to pain? O O
• Do you have feelings of unprovoked anger? O O
• Are you losing interest in life? O O
SECTION E – DOPAMINE
• Do you have feelings of hopelessness? O O
• Do you have self-destructive thoughts? O O
• Do you have an inability to handle stress? O O
• Do you have anger and aggression while
under stress? O O
• Do you feel you are not rested even after long
hours of sleep? O O
• Do you prefer to isolate yourself from others? O O
• Do you have unexplained lack of concern for
family and friends? O O
• Are you distracted easily? O O
• Do you have an inability to finish tasks? O O
• Do you feel the need to consume caffeine to
stay alert? O O
• Do you feel your libido has been decreased? O O
• Do you lose your temper for minor reasons? O O
• Do you have feeling of worthlessness? O O
SECTION F – GABA
• Do you feel anxious or panic for no reason? O O
• Do you have feelings of dread, or pending gloom? O O
• Do you feel knots in you stomach? O O
• Do you have feelings of being overwhelmed
for no reason? O O
• Have feelings of guilt about everyday decisions? O O
• Does your mind feel restless? O O
• Is it difficult to turn your mind off when you
want to relax? O O
• Do you have disorganized attention? O O
• Do you now worry about things you were not worried
about before? O O
• Do you have feelings of inner tension and
inner excitability? O O
SECTION G - ACETYLCHOLINE
• Do you feel your visual memory (shapes & images)
is decreased? O O
• Do you feel your verbal memory is decreased? O O
• Do you have memory lapses? O O
• Has your creativity been decreased? O O
• Has your comprehension been diminished? O O
• Do you have difficulty calculating numbers? O O
• Do you have difficulty recognizing objects & faces? O O
• Do you feel like your opinion about yourself
is changed? O O
• Are you experiencing excessive urination? O O
• Are you experiencing slower mental response? O O
Metabolic Imbalances:
Alkalosis
Muscle cramps O O
Allergies O O
Asthma O O
Fatigue O O
Poor Digestion and Assimilation of food O O
Muscular weakness O O
Bursitis O O
Osteoarthritis O O
Constipation O O
Frequent urination O O
Increased volume of urine O O
Nervousness O O
Over-excitability O O
Muscle spasms O O
Seizures O O
Rheumatic type pain O O
Stiffness in muscles O O
Stiffness in joints O O
Neuro-muscular hyper-excitability O O
Lightheadedness O O
Tingling/numbness of the extremities O O
Acidosis
Dry mouth O O
Poor digestion and assimilation of food O O
Joint and Muscle pain O O
Shortness of Breath O O
Decreased urine volume O O
Gastric hydrochloric acid insufficiency O O
Rapid Pulse/Heart Beat O O
Allergies O O
Poor retention of Important minerals O O
Fatigue O O
Cold sweat to Palms of hands O O
Aluminum consumption: (creates acidosis)
Drink public water supplies O O
Use Aluminum cookware O O
Use Canned fruits and vegetables O O
Take Antacids O O
Use Baking powder O O
Aluminum foil /containers O O
Use antiperspirants O O
Eat Commercially refined salt O O
Electrolyte insufficiency
Low blood Pressure O O
Chronic fatigue O O
Muscular weakness O O
Anemia O O
Postural dizziness O O
Decreased libido O O
Poor circulation O O
Deficient self assurance O O
Osteoporosis O O
Accelerated aging O O
Depression or Anxiety O O
Electrolyte Stress Imbalance
High Blood Pressure O O
Hardening of the Arteries O O
Heart Attack O O
Stroke O O
Poor Circulation O O
Take Antacids O O
Drink Softened Water O O
Drink Municipal (chemically treated) Water O O
Drink Fluoridated, Chlorinated Water O O
Anaerobic / Anabolic
Increased Volume of Urine O O
Blood Pressure High O O
Rapid Heart Rate O O
Somnolence (Sleepiness) O O
Constipation O O
Protrusion of the eyeball O O
Osteoarthritis O O
Capillary Hemorrhage/oozing O O
Allergies: Airborne O O
Food O O
Asthma O O
Hives O O
Increased Urine output O O
Lack Energy O O
Joint and Muscle Pain O O
Depression O O
Dizziness O O
Dysaerobic / Catabolic
Pain O O
Itching O O
Vertigo O O
Difficult or labored breathing O O
Hearing loss O O
Manic depressive O O
Low Volume of Urine O O
Blood Pressure Low O O
Slow Heartbeat O O
Insomnia O O
Diarrhea O O
Rheumatoid Arthritis O O
Gall Bladder Colic O O
Psoriasis O O
Schizophrenia O O
Migraine O O
Multiple Sclerosis O O
Decreased Urine output O O
Lack of Energy O O
Blood Sugar Problems O O
Joint and Muscle Pain O O
Nervous Tension O O
Colitis and other intestinal problems O O
Ketogenic (slow oxidizer)(the no's) /Glucogenic (fast oxidizer)(the yes answers)
Appetite strong at breakfast No Yes
Appetite strong at lunch No Yes
Appetite strong at dinner No Yes
Going without food for four or more
hours is uncomfortable No Yes
I often get hungry and need to snack
between meals No Yes
I live to eat rather than eat to live No Yes
Meat/ fish at meals make me more energetic No Yes
Vegetarian meals are not satisfactory to me No Yes
Eating meat or fatty food restores my energy No Yes
I prefer salty and/or fatty foods to sweet foods No Yes
Fruits Alone generally do not satisfy me No Yes
Fasting is very difficult No Yes
Eating before bedtime improves my sleep No Yes
Orange juice in the morning does not
agree with me No Yes
Coffee tends to make me feel wired or jittery No Yes
My eyes and /or nose tend to be moist No Yes
I need to urinate often during the day No Yes
I tend to cough or clear my throat frequently No Yes
I prefer to sleep in, in the morning No Yes
If I cut myself, the wound heals quickly No Yes
Ketogenic (slow oxidizer)
Lack of Energy O O
Physical and Mental Fatigue O O
Depression/anxiety O O
Gallbladder trouble O O
Shortness of Breath O O
Over Weight or Under Weight O O
Addicted to coffee/tea/cola/chocolate O O
Glucogenic (fast oxidizer)
Fatigue O O
Depression/Anxiety O O
High or low blood sugar O O
Under or over weight O O
Premature aging O O
Addicted to coffee/tea/cola/chocolate O O
Sympathetic Imbalance
Night Sweats O O
Pulse Rate Increased; arrhythmia O O
Oliguria (deficient urine) O O
Cold Sweat on hands, or, cold dry hands O O
Nervous Tension O O
Insomnia O O
Tremors O O
Dry Mouth O O
Bulging eyes O O
Low Resistance to Infection O O
Poor Circulation O O
Heart; Kidney problems O O
Blood Pressure problems O O
Food allergies O O
Poor digestion and Assimilation of Nutrients O O
Blood Sugar Problems:
Hypoglycemia O O
Diabetes O O
Indigestion; ulcers O O
Gallbladder trouble O O
Bowel problems O O
High Blood Pressure O O
Low Energy O O
Parasympathetic Imbalance
Excessive sweating of hands and feet O O
Dry skin O O
Pulse Decreased O O
Polyuria (excess urine) O O
Hands warm and dry O O
Nervous tension O O
Depression O O
Anxiety O O
Somnolence or insomnia O O
Saliva and tear quantity increased O O
Deep Set Eyes O O
Osteoarthritis O O
Poor circulation O O
Weak heart O O
Indigestion O O
Ulcers O O
Bowel problems O O
Colitis O O
Allergies O O
Asthma O O
Blood Sugar Problems:
Hypoglycemia O O
Diabetes O O
Arthritis O O
Low energy O O
Prostaglandin Imbalance
Allergies O O
Pre-menstrual syndrome O O
Arthritis O O
Headaches O O
Joint and muscle pain O O
Hardening of the Arteries O O
Inflammation in tissues O O
I Use Soy, Corn, Sunflower or Canola Oils O O
I Use grain fed beef, pork, or lamb O O
I Use “farmed” salmon, trout or catfish O O
I Use Margarine, Shortening or Mayonnaise O O
Joints
Neck Pain (R) (L) O O
Pain Under Skull O O
Neck Muscles Tight O O
Shoulder Pain (R) (L) O O
Can’t Raise Arm O O
Elbow Pain (R) (L) O O
Wrist Pain (R) (L) O O
Numbness in wrist/hand O O
Swollen/Painful Fingers O O
Loss of hand strength O O
Upper low back pain O O
Pain under scapula O O
Midback Pain O O
Upper Low Back Pain O O
Low Back Pain O O
Increased Pain Sitting O O
Sacroiliac Joint Pain O O
Pain Down Leg (R) (L) O O
Hip Pain (R) (L) O O
Frontal Pelvic Pain O O
Knee Pain (R) (L) O O
Night Leg Cramps O O
Ankle Pain (R) (L) O O
Foot Pain (R) (L) O O
Bladder
Discolored Urine O O
Excessive Urine O O
Scanty Urination O O
Painful Urination O O
Difficulty in Starting O O
Organ Systems:
Colon
Feeling that bowels do not empty completely O O
Lower abdominal pain relief by passing stool or gas O O
Alternating constipation and diarrhea O O
Diarrhea O O
Constipation O O
Hard dry or small stool O O
Coated tongue of “fuzzy” debris on tongue O O
Pass large amount of foul smelling gas O O
More than 3 bowel movements daily O O
Do you use laxatives frequently O O
Bloody Stool O O
Black Stool O O
Hemorrhoids O O
Hypochlorhydria (not enough stomach acid)
Excessive belching, burping or bloating O O
Gas immediately following a meal O O
Offensive breath O O
Difficult bowel movements O O
Sense of fullness during and after meals O O
Difficulty digesting fruits and vegetables O O
Undigested foods found in stools O O
Hyperacidity (ulcer)
Stomach pain, burning , aching immediately after eating O O
Stomach pain, burning or aching -4 hours after eating O O
Do you frequently use antacids O O
Felling hungry an hour or two after eating O O
Heartburn when laying down or bending forward O O
Temporary relief from antacids, food,
milk, carbonated beverages O O
Digestive problems subside with rest and relaxation O O
Heartburn due to spicy foods, chocolate, citrus,
Peppers, alcohol and caffeine O O
Small Intestine (Pancreas)
Roughage and fiber cause constipation O O
Indigestion and fullness lasts 2-4 hours after eating O O
Pain, tenderness, soreness on left side
under rib cage bloated O O
Excessive passage of gas O O
Nausea and/or vomiting O O
Stool undigested, foul smelling, mucous-like,
greasy or poorly formed O O
Frequent urination O O
Increased thirst and appetite O O
Difficulty loosing weight O O
Biliary Insufficiency/Stasis (liver and gallbladder)
Greasy or high fat foods cause distress O O
Lower bowel gas and or bloating
several hours after eating O O
Hemorrhoids O O
Bitter metallic taste in mouth, especially in the morningO O
Unexplained itchy skin O O
Yellowish cast to eyes O O
Stool color alternates for clay colored to normal brown O O
Reddened skin, especially palms O O
Dry or flaky skin and/or hair O O
History of gallbladder attacks or stones O O
Have you had your gallbladder removed No Yes
Adrenal Hypofunction
Cannot stay asleep O O
Crave salt O O
Slow starter in the morning O O
Afternoon fatigue O O
Dizziness when standing up quickly O O
Headaches with exertion or stress O O
Weak nails O O
Adrenal Hyperfunction
Cannot fall asleep O O
Perspire easily O O
Under high amounts of stress O O
Weight gain when under stress O O
Wake up tired even after 6 or more hours of sleep O O
Excessive perspiration or perspiration with
little or no activity O O
Hypothyroid
Tired, sluggish O O
Feel cold-hands, feet, all over O O
Require excessive sleep to function properly O O
Increase in weight gain even with low-calorie diet O O
Gain weight easily O O
Difficult, infrequent bowel movements O O
Depression, lack of motivation O O
Morning headaches that wear off as
the day progresses O O
Outer third of eyebrow thins O O
Thinning of hair on scalp, face or genitals or
excessive falling hair O O
Dryness of skin and/or scalp O O
Mental sluggishness O O
Thyroid Hyperfunction
Heart Palpitations O O
Inward trembling O O
Increased pulse even at rest O O
Nervousness and emotional O O
Insomnia O O
Night sweats O O
Difficulty gaining weight O O
Pituitary Hypofunction
Diminished sex drive O O
Menstrual disorders of lack of menstruation O O
Increased ability to eat sugars without symptoms O O
Pituitary Hyperfunction
Increased sex drive O O
Tolerance to sugars reduced O O
“Splitting” type headaches O O
Prostate (Male Only)
Urination difficulty or dribbling O O
Urination frequent O O
Pain inside of legs or heels O O
Feeling of incomplete bowel evacuation O O
Leg nervousness at night O O
Andropause (Males Only)
Decrease in libido O O
Decrease in spontaneous morning erections O O
Decrease in fullness of erections O O
Difficulty in maintaining morning erections O O
Spells of mental fatigue O O
Inability to concentrate O O
Episodes of depression O O
Muscle soreness O O
Decrease in physical stamina O O
Unexplained weight gain O O
Increase in fat distribution around chest and hips O O
Sweating attacks O O
More emotional than in the past O O
Menstruating Females Only
Are you menopausal No Yes
Alternating menstrual cycle lengths No Yes
Extended menstrual cycle, greater than 32 days No Yes
Shortened menses, less than every 24 days No Yes
Scanty blood flow O O
Heavy blood flow O O
Breast pain and swelling during menses O O
Pelvic pain during menses O O
Irritable and depressed during menses O O
Acne break outs O O
Facial hair growth O O
Hair loss/thinning O O
Menopausal Females Only
How many years have you been menopausal? ________
Have you had uterine bleeding since menopause?No Yes
Hot flashes O O
Mental fogginess O O
Disinterest in sex O O
Mood swings O O
Depression O O
Painful intercourse O O
Shrinking breast O O
Facial hair growth O O
Acne O O
Increased vaginal pain, dryness or itching O O
EENT
Eye Strain O O
Eye Inflammation O O
Vision Blurred O O
Ear Pain O O
Ear Noises/buzzing O O
Hearing Loss O O
Ear Discharge O O
Nose/Sinus Pain O O
Nose Bleeding O O
Nose Discharge O O
Nerves/Brain
Tingling in legs O O
Tingling in calves O O
Tingling in toes O O
Tingling in arms O O
Tingling in Hands/Fingers O O
Other loss of feeling O O
Head Feels Heavy O O
Paralysis O O
Dizziness O O
Fainting O O
Convulsions/Seizures O O
Muscle Jerking O O
Impotence O O
Forgetfulness O O
Shaking/Tremors O O
Difficulty Reading O O
Memory Loss O O
Cold Sweats O O
Feel Hot O O
Light bothers eyes O O
Loss of Balance O O
Loss of Smell O O
Loss of Taste O O
Frontal Headache O O
Neck Headache O O
Migraine Headache O O
Heart/Lung
Chest/Rib Pain O O
Pain over Heart O O
Difficult Breathing O O
Persistent Cough O O
Coughing Phlegm O O
Coughing Blood O O
Irregular Heartbeat O O
Rapid heartbeat O O
Varicose Vein Pain O O
Hands/Feet Cold O O
Blue Nail Beds No Yes
Clubbed Nails No Yes
Ear Lobe Creased No Yes
Systemic Yeast Infection
Bloated, Abdominal Distention O O
Chronically Fatigued O O
Achy Muscles and Joints O O
Foggy Headed O O
Depressed O O
Vaginal Yeast Infection O O
Coated Tongue O O
Rashes O O
Have been on cortisone over 1 year No Yes
Have been on birth control over 1 year No Yes
Have used Antibiotics several times in life No Yes
Athlete’s Foot or Nail Fungus No Yes
Recurring Sinus or Ear Infections
(as a Child or an Adult) No Yes
Unusual Stool Color or Shape No Yes
Chemical / Physiologic Stress:
I over or under eat O O
I have Incomplete / acid indigestion O O
I have Vitamin / mineral deficiencies O O
I have Food sensitivities O O
I experience Sleep cycle disturbance O O
I live or work in high traffic areas - low oxygen O O
I have Allergies (i.e. pollens etc.) O O
I have Environmental sensitivities O O
I have Bacteria or virus infections O O
I have Yeast and fungus infections O O
I have Parasites O O
I have mercury fillings /Heavy metals O O
I use or am around Pesticides O O
I take medications - Medical drug residues O O
I use Recreational drugs O O
I use Alcohol, tobacco O O
I am exposed to Excess heat or cold O O
I drink treated city water O O
I use antiperspirants that contain aluminum O O
I use Plug-in air fresheners O O
I use several medications - drug interactions O O
I have been Immunized O O
Diet Stress:
I use Artificial food additives or sweeteners O O
I use fried foods - Rancid fats (free radicals) O O
I use packaged foods - Partially hydrogenated oils O O
I use vegetable/ seed/ polyunsaturated oils O O
I use sugary snacks (diabetes/ insulin resistance) O O
I use milk (hormone excessesand heart damage) O O
I use flour products (excitotoxins/ gut inflammation) O O
I use soy products (hormone imbalances) O O
I use MSG (brain damage causing) O O
I use salty snacks (hydration dysregulation) O O
I drink water with my meals (poor digestion) O O
I drink more than 1 serving of alcohol per day O O
I binge eat O O
I purge O O
I skip meals O O
I diet a lot O O
I skip eating my vegetables O O
I eat fast food (Contaminated food) O O
Psychological / Energetic Stresses:
1. Emotional Stresses:
Family issues / stress O O
Parenting-new & continuing O O
Work / bosses or co-workers O O
Money / taxes / etc. O O
Relationships (most aspects) O O
Past / regret or guilt O O
Future / worry / conjecture O O
Aging – too much or too little O O
Social stress / peer interactions O O
Self worth / esteem O O
Pursuit of love O O
Inappropriate anger O O
Excessive attention need O O
Death / loss / grief / divorce O O
Sudden change - good or bad O O
Fear / phobias / anxiety O O
Social order / ethics / politics O O
Sex and gender concerns O O
Addictions & using O O
Obsessive-compulsive behaviors O O
Survival concerns O O
Authority issues O O
Victim experience O O
Over concern for others O O
Dependency issues/ growing up O O
2. Mental Stresses:
Attitudes / beliefs /Superstitions O O
Time & goal management O O
Need for control O O
Negative habits O O
Unrealistic expectations / immaturity O O
Information overload O O
Recent bad news / shock O O
Old unresolved traumas O O
Judging or being judged O O
Blocked expression O O
Subconscious / conscious inhibitions O O
Negative Subconscious beliefs O O
Poor life skill development O O
Assumptions & faulty logic O O
Conflicting desires or wants O O
Poor boundaries / sense of self O O
Deficient assertiveness skills O O
False desire implantation-(advertising) O O
Negative imagery exposure-(violence on TV etc.) O O
3. Energetic Stresses:
Electro-magnetic pollution (EMFs) O O
Aesthetic deprivation (lack of beauty) O O
Radiation / sunburn O O
Insufficient natural light O O
Acoustic stress (sound or noise) O O
4. Spiritual Stresses:
Disharmony with life O O
Purpose & meaning missing O O
God’s will vs. ego self will O O
Non-acceptance of what is O O
Narcissism / self-centered O O
Attachment to right and wrong O O
No outflow to others O O
Failed connection / participation O O
Structural Functioning Stress:
Traumatic injury (i.e. a fall) O O
Whiplash injury O O
Over exertion / lifting stress O O
Repeated micro-trauma injury O O
Poor workstation ergonomics O O
Not enough exercise / excess sitting O O
Poor muscle tone O O
Balance / coordination problems O O
Joint pain affecting motion O O
Bad posture O O
Weak ligaments O O
Foot / knee problems O O
Subluxations of the spine O O
TMJ (jaw) dysfunction O O
Scars & adhesions O O
Bursitis / tendonitis /Disc inflammation O O
Diaphragm tension O O
Congested lymph glands O O
Stomach / bowel problems O O
Liver or kidney trouble O O
Sinus problems O O
Nerve irritation-inflammation O O
Impaired feeling sensation O O
Visual disturbances O O
Teeth and gum problems O O
Infections/ Overt disease conditions O O
Genetic disorders O O
Which of these symptom groupings is most important to you?
Second most important?
Any and all of these conditions decrease your health and cause eventual pain and dysfunction. They are cumulative and additive, meaning they gradually gang up on you and pull you down. By the time you become unhealthy enough for you to show a diagnosable disease, there are usually a dozen or more of these problems lowering your health and creating the foundations for disease.
