| I experience problems falling asleep. | | | | | |
| I experience problems staying asleep. | | | | | |
| I frequently experience a second wind (high energy) late at night. | | | | | |
| I have energy highs and lows throughout the day. | | | | | |
| I feel tired all the time or I am easily fatigued. | | | | | |
| I need caffeine (coffee, tea, cola, etc) to get going in the morning. | | | | | |
| I usually go to bed after 10 pm and/or I frequently get less than 8 hours of sleep per night. | | | | | |
| I suffer with gas, bloating, indigestion and/or stomach pain. | | | | | |
| I tend toward constipation (average of less than one bowel movement per/day), diarrhea or alternate between the two. Or I have bowel issues that come and go. | | | | | |
| I have heartburn or I take anti-acids to treat or prevent heartburn. | | | | | |
| My sex drive is lower than it used to be. | | | | | |
| I suffer from depression, or have recently been experiencing feelings of depression such as sadness, or loss of motivation. | | | | | |
| If I skip meals I feel low energy or foggy and disoriented. | | | | | |
| I feel anxious inside – like a ‘wired and tired’ feeling or have ‘anxiety attacks’ that come and go. | | | | | |
| My ability to handle stress has decreased or find that I am easily irritated or upset. | | | | | |
| I have had one or more stressful major life events. (ie: divorce, death of a loved one, job loss, new baby, new job) | | | | | |
| I tend to overwork with little time for play or relaxation for extended periods of time. | | | | | |
| I crave sweets. | | | | | |
| I frequently skip meals or eat sporadically. | | | | | |
| I am experiencing increased physical complaints such as muscle aches, headaches, or more frequent illnesses. | | | | | |
