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A. Weight Loss Resistance Profile physiological imbalance assessment

YOUR WEIGHT LOSS GOAL 1. Do you have a weight loss goal in mind? Yes, Id like to lose a specific number of pounds Yes, Id like to lose enough weight to be within a healthy range for my height, but Im not sure how many pounds I want to lose Yes, Id like to lose enough weight so that my clothes fit better, or so I can wear a smaller size Yes, Id like to lose weight around my mid-section (abdomen, hips, and waist) No, I do not have a specific goal in mind but want to learn about dealing with my challenges losing weight 2. How quickly do you want to reach your goal? Less than 30 days Less than 60 days It doesnt matter, as long as I can keep it off! 3. Who will be supporting your weight loss efforts? (select all that apply) My spouse or partner A community support group A close friend (s) Family member (s) 4. Whats your BMI? in. What is your weight? lbs.

What is your height? 5.

What is the relationship between your hips and your waist? My hips are much larger than my waist My hips are slightly larger than my waist My hips and my waist are the same size My hips are slightly smaller than my waist My hips are much smaller than my waist

YOUR EXPERIENCE WITH WEIGHT LOSS Answer yes or no to each of these questions 1. 2. 3. 4. 5. I am on a diet and cannot lose weight I lose weight, only to gain it back My body fat is moving to my middle Many people in my family are overweight I eat when I am stressed, sad, and/or anxious Yes Yes Yes Yes Yes No No No No No

WHAT ABOUT EXERCISE AND PHYSICAL FITNESS? Check which best describes you during the past 30 days I do intense cardiovascular exercise for at least 30 minutes, 3 or more times per week I do moderate exercise for at least 30 minutes, 3 or more times per week I dont exercise, but I am very active in my day-to-day activities I dont exercise, and most of my daily activities are sedentary

Do you look forward to exercising? Always Usually Sometimes Hardly ever Never

If you do exercise, do you feel good afterwards? Always Usually Sometimes Hardly ever

Rate the symptoms that you have experience in the last 3 months on a scale from 1 to 5. If you did not experience the symptom, please rate it as 1. Heres how to rate your symptoms: 1 = I do not experience this symptom with any regularity 2 = the symptom is a minor problem. I notice the symptom but can manage most of the time 3 = the symptom is a moderate issue for me. I can manage it some of the time but I sometimes struggle 4 = the symptom is a real problem, but I try to push myself through it 5 = the symptom is severe. I can barely function Symptom 1. 2. 3. 4. 5. 6. 7. 8. 9. Heavy or irregular periods (women only) Intense mood swings and food cravings before periods (women) Hot flashes (women), night sweats, and/or palpitations Vaginal dryness (women only) and low libido (men & women) Exhaustion and fatigue Insomnia, difficulty falling asleep, or difficulty staying asleep Anxiety Constant stress Binge eating 1 2 3 4 5

10. Craving carbohydrates, sweets, or alcohol 11. Feeling unfocused or fuzzy thinking 12. Feeling tense or guilty

How do you like to feel after completing a weight loss program? Check all that apply: I have more energy I feel stronger I sleep better My clothes fit better I feel proud of myself I feel more attractive My partner or spouse is proud of me I think more clearly I feel less moody I have fewer food cravings I feel less bloated People say I look great Im a healthy role model for my children I have more confidence

B. Adrenal Health Assessment

WHAT IS YOUR BODY TELLING YOU? Rate the symptoms of adrenal imbalance that you have experienced in the last 3 months on a scale of 1 to 5. If you did not experience the symptoms, please rate it as 1. Heres how to rate your symptoms: 1 = I do not experience this symptom with any regularity 2 = the symptom is a minor problem. I notice the symptom but can manage most of the time 3 = the symptom is a moderate issue for me. I can manage it some of the time but I sometimes struggle 4 = the symptom is a real problem, but I try to push myself through it 5 = the symptom is severe. I can barely function Symptom 1. 2. 3. 4. 5. 6. Difficulty falling asleep Difficulty staying asleep Waking up tired Falling tired, especially in the afternoon Feeling fatigued throughout the day Craving sweets, carbohydrates, or sugar 1 2 3 4 5

Symptom 7. 8. 9. Craving caffeinated beverages such as coffee, soda, energy drink Craving salty foods Unexpected weight gain, especially around the middle

10. Temperature intolerance inability to tolerate cold or hot temp 11. Irritability or inability to control temper 12. Feeling forgetful, fuzzy-minded, or absent-minded 13. Feeling anxious 14. Lack of energy or feeling drained 15. Feeling stressed almost all the time WHICH SITUATION BELOW BEST DESCRIBES YOU?

You feel speedy and energized all day. You are constantly racing. You find it hard to settle down at night to sleep, and your sleep is somewhat irregular. Even though you are running around, you still feel overwhelmed by fatigue from time to time You are exhausted first thing in the morning and have a hard time waking up without consuming coffee or sugar. You spend the day feeling tired and so you continue using caffeinated beverages and sugar to keep you going. By the end of the day, the drinks and sweets have caught up with you and you have a hard time settling down. Now, you cant fall asleep and, as a result, you wake up tired again the next morning and the same cycle begins again Your daily demands and stresses have left your adrenal reserves simply exhausted. You feel as if you never have energy, and despite being worn out, you cannot sleep at night. As a result, you are barely able to summon the energy needed to meet the basic demands of your family and home life, and your job. You have been so tired for so long that you are beginning to wonder if you will ever feel like yourself again None of the situations above describes me

C. Hormonal Health Profile

WHAT IS YOUR BODY TELLING YOU? Check any symptom youve experienced in the last 3 months. Heres how to score your symptoms: Mild: Moderate: Severe: A minor issue it doesnt affect me much A real problem, but I push myself through it I can barely function or deal with it MILD MODERATE SEVERE

If you did not experience the symptom, do NOT check anything 1. 2. 3. 4. 5. 6. 7. 8. 9. My menstrual periods are irregular I have hot flashes or night sweats I suffer from PMS cramps, breast tenderness, nausea, headaches, irritability I have difficulty falling asleep I have difficulty staying asleep I feel very tired, especially in the afternoon I am fatigued or have loss of energy I am sad, irritable or depressed I am anxious, have anxiety attacks, or have heart palpitations

10. I am forgetful, fuzzy-minded or absent-minded 11. I sometimes feel overwhelmed, confused, or just not myself 12. I experience bloating, gas, or bouts of diarrhea 13. I feel stiff or achy in my joints, especially in the morning 14. I feel that Ive gained weight compared to last year, esp around the middle 15. My interest in sex isnt what it used to be

MILD 16. I suffer from vaginal dryness 17. I crave sweets, carbohydrates, or alcohol 18. I have hair or skin that is dry, fragile, or thinning 19. I have lost inches of height 20. I have suffered from broken or fractured bones 21. I suffer from yeast or urinary tract infections WHAT DEMANDS ARE YOU MAKING OF YOUR BODY? Answer Yes or No to each of these questions 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Are you being treated for any disease or serious condition? Have you been diagnosed with osteoporosis or osteopenia? Have you been diagnosed with a thyroid condition? Have you been diagnosed with insulin resistance? Is our work a source of stress for you? Do you feel overscheduled and rushed? Do you skip meals or follow popular diet plans? Do you eat out more than 3 x a week? Do you experience a lot of conflict or stress in your relationships? Do you have caffeine or soft drinks more than 1 x a day? Are you taking more than one prescription medication? Do you frequently take antibiotics? Are you a frequent traveller? Do you have a family history of heart disease? Have you experienced a major trauma or loss in the last 5 yrs? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

MODERATE

SEVERE

No No No No No No No No No No No No No No No

WHAT KIND OF SUPPORT ARE YOU GIVING YOUR BODY? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Do you eat protein every meal? Do you eat 5 or more servings of fruit & vegetables a day? Do you minimize simple carbohydrates and sweets? Do you minimize alcohol intake? Do you exercise 4 or more times a week? Do you get 7-8 hours of sleep per night? Do you rest when you are feeling run-down or fatigued? Do you feel you make adequate time for your needs? Do you take some time for yourself every day? Do you try to minimize toxins and processed food on your diet? Do you try to minimize stress in your daily life? Do you take high-quality supplements w/ essential fatty acids? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No

HISTORY 1. Are you on HRT* or trying to wean yourself off of it? *Hormone Replacement Therapy 2. 3. Have you had a hysterectomy? Are you currently using birth control pills, patch or ring? Yes Yes Yes No No No