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Here is a great way to assess your health needs. We provide health questionnaires to help you identify problem areas within your health.

Health Questionnaires

Candida | Gluten Sensitivity | Food Allergies | Hypoglycemia

(All information is held in strict confidentiality and will not be shared or sold)

HYPOGLYCEMIA QUESTIONNAIRE

Full Name:
Email Address:
Confirm Email Address:
Phone:

Age:

Sex:

Weight:

Height:

(inches)


Conditions: Check each symptom according to its severity:


PART A	Problem Never Occurs	Mild and Occurs Occasionally	Moderate and/or Occurs at Least Once a Week	Severe and Occurs Frequently
1. Tired all the time
2. Hungry between meals or at night
3. Depressed
4. Insomnia, awakening with inability to return to sleep
5. Wake up after a few hours sleep
6. Fearful (Overwhelmed by people, places, or things)
7. Can't decide easily
8. Can't concentrate
9. Poor memory
10. Worry frequently
11. Highly emotional
12. Moody
13. Cry easily, or feel like crying inside
14. Fits of anger
15. Magnify insignificant details (Mountains out of molehills)
16. Eat candy, cake, or drink soda pop
17. Eat bread, pasta, potatoes, rice, or beans
18. Consume alcohol
19. Drink more than three cups of coffee or cola drinks daily
20. Crave candy, soda, or coffee between meals or mid-afternoon
21. Can't work well under pressure
22. Headaches
23. Sleepy during the day
24. Sleepy or drowsy after meals
25. Lack of energy
26. Can't get started in the morning
27. Eat when nervous



PART B	Problem Never Occurs	Mild and Occurs Occasionally	Moderate and/or Occurs at Least Once a Week	Severe and Occurs Frequently
1. Stomach cramps or "nervous stomach"
2. Allergies: asthma, hay fever, skin rash, sinous trouble, etc.
3. Fatigue relieved by eating
4. Suicidal thought or tendencies; feeling of hopelessness
5. Bored
6. Bad dreams
7. Irritable before meals
8. Heart beats fast ( palpitations )
9. Get shaky inside when hungry
10. Feel faint if meal is delayed
11. Ulcers, gastritis, chronic indigestion, abdominal bloating
12. Cold hands or feet
13. Blurred vision
14. Bleeding gums
15. Dizziness, giddiness, or light headedness
16. Aware of breathing heavily
17. Bruise easily
18. Reduced sex drive
19. Uncoordination ( drop or bump into things )
20. Sweating excessively
21. Unsocial or antisocial behavior
22. Muscle twitching or cramps
23. Skin aches or itches
24. Phobias ( excessive fear or some thing or situation )
25. Hallucinations
26. Convulsions
27. Trembling ( shaking ) of the hands

By checking this box, I am giving permission for the results of this questionnaire to be sent to Dr. Patricia Bender and to be contacted by her to discuss them

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