In-Depth Health Evaluation from the Perspective of Traditional Chinese Medicine (TCM) at ActiveHerb
  • Miami Holistic Center

    Weight Loss Program Questionnaire

    Complete prior to your first clinic consultation

    Our clinic asks clients to fill out an extensive symptom questionnaire so that we can isolate the causes of their problems.  These eight key sections will help identify your particular physical imbalances.  We use this information to tailor a program to your specific nutritional needs.

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    For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

    Your Full Name:
    Sex: male female
    Date of Birth:
    Marital Status: single married divorced widowed

    How did you hear about us:

    What kind of food issues and weight problems do you have?

    How much weight do you want to lose?

    Do you have any allergies?  If yes, please list.

    Please describe what types of diet/weight programs you have done in the past:

    What did you like about what you have done before?

    What did you dislike about it and what did not work?

    If you could design your own program, what would be the most important elements in it?

    What habits do you want to change?

    What unhealthy or addictive food choices are you currently making?

    Do you ever find yourself eating when not hungry?

    Do you feel out of control with food sometimes?

    Do you have binges? If yes, how often?

    What do you do afterwards (e.g. fast, diet, exercise, vomit?)

    Do you crave or binge on certain types of foods at, certain times of the day? If yes, please describe

    Why do you want to resolve these issues?

    If these issues were resolved, how would you feel?

    How do you feel about your body?

    When do you feel satisfied with yourself (Are you ever satisfied with yourself?)

    Do you find that you know what to do (eat) but cannot seem to do it?

    Have you engaged in an exercise program recently? If yes, please describe:

    What type of physical activities do you enjoy doing? Please describe:

    Why don’t you do the physical activities you enjoy doing (e.g. time, energy, other people’s needs come first)

     If you were the weight you want to be and enjoyed a healthy body, how would you act differently?

    How would your life feel to you? How would you feel to yourself?



    Note the number next to any symptom that applies to you and follow the directions at the end of each section to calculate your score.

    1. Is depleted brain chemistry the problem?

    4  Sensitivity to emotional (or physical) pain; cry easily

    4  Eat as a reward or for pleasure, comfort, or numbness

    4  Worry, anxiety, phobia, or panic

    4  Difficulty getting to sleep or staying asleep

    3  Difficulty with focus, attention deficits

    2  Low energy, drive, and arousal

    4  Obsessive thinking or behavior

    4  Inability to relax after tension, stress

    3  Depression, negativity

    4  Low self-esteem, lack of confidence

    4  More mood and eating problems in winter or at the end of the day

    3  Irritability, anger

    4  Use alcohol or drugs to improve mood

    Total Score (add all the numbers you noted) 

    2. Are you suffering because of low-calorie dieting?

    4  Increased cravings for and focus on food; overeating

    4  Regain weight after dieting, more than was lost

    3  Increased moodiness, irritability, anxiety, or depression

    3  Less energy and endurance

    3  Usually eat less than 2,100 calories a day

    3  Skip meals, especially breakfast

    3  Eat mostly low-fat carbohydrates (bagels, pasta, frozen yogurt, and others)

    2  Constantly think about weight

    2  Use aspartame (NutraSweet) daily

    2  Take Prozac or similar serotonin-boosting drugs

    2  have become vegetarian

    3 I ncreased self-esteem

    4  Have become bulimic or anorectic

    Total Score

    3. Are you struggling with blood sugar instability or high stress?

    4  Crave a lift from sweets or alcohol, but later experience a drop in energy and mood after ingesting them

    4  Family history of diabetes, hypoglycemia, or alcoholism

    3  Nervous, jittery, irritable, headachy, weak, or teary on and off throughout the day; may be calmer after meals

    3  Frequent infections, allergies, or asthma, especially when weather changes

    3  Mental confusion, decreased memory, hard to focus or get organized

    4  Frequent thirst 3 Night sweats (not menopausal)

    5  Light-headed, especially on standing up

    4  Crave salty foods or licorice

    4  Often feel stressed, overwhelmed, and exhausted

    4  Dark circles under eyes or eyes sensitive to bright light

    4  More awake at night

    Total Score

    4. Do you have unrecognized low thyroid function?

    4  Low energy

    4  Easily chilled (especially hands and feet)

    4  Other family members have thyroid problems

    4  Can gain weight without overeating; hard to lose excess weight

    3  Have to force yourself to do even moderate exercise

    4  Find it hard to get going in the morning

    3  High cholesterol

    3  Low blood pressure

    4  Weight gain began near the start of menses, a pregnancy, or menopause

    3  Chronic headaches

    3  Use food, caffeine, tobacco, and/or other stimulants to get going

    Total Score

    5. Are you addicted to foods you are actually allergic to?

    3  Crave milk, ice cream, yogurt, cheese, or doughy foods (pasta, bread, cookies, among others) and eat them frequently

    3  Experience bloating after meals

    4  Gas, frequent belching

    3  Digestive discomfort of any kind’

    3  Chronic constipation and/or diarrhea

    4  Respiratory problems, such as asthma, postnasal drip, Congestion

    3  Low energy or drowsiness, especially after meals

    4 Allergic to milk products or other common foods

    3  Under eat or often prefer beverages to solid food

    3  Avoid food or throw up food because bloating after eating makes you feel fat or tired

    4  Can’t gain weight

    3  Hyperactivity or manic-depression

    3  Severe headaches, migraines

    4  Food Allergies in family

    Total Score

    6. Are your hormones unbalanced?

    4  Premenstrual mood swings

    4  Premenstrual or menopausal food cravings

    4  Irregular periods or migraines

    3  Experienced a miscarriage, an abortion, or infertility

    4  Use(d) birth control pills or other hormone medication

    3  Uncomfortable periods – cramps, lengthy or heavy bleeding, or sore breasts

    4  Peri- or postmenopausal discomfort (e.g., hot flashes, weight gains, sweats, insomnia, or mental dullness)

    3  Skin eruptions with period

    Total Score

    7. Do you have yeast overgrowth triggered by antibiotics, cortisone, or birth control pills?

    4  Often bloated, abdominal distention

    3  Foggy-headed

    2  Depressed

    4  Have chronic fungus on nails or skin or athlete’s foot

    3  Recurring sinus or ear infections as an adult or child

    3  Achy muscles and joints

    4  Rashes

    3  Stool unusual in color, shape or consistency

    Total Score

    8. Do you have fatty acid deficiency?

    4  Crave chips, cheese, and other rich foods more than, or in addition to, sweets and starches

    4  Have ancestry that includes Irish, Scottish, Welsh, Scandinavian, or coastal Native American

    3  Alcoholism and depression in the family history

    3  High cholesterol, low HDL levels

    4  Feel heavy, uncomfortable, and “clogged up” after eating fatty foods

    4  History of hepatitis or other liver or gallbladder problems

    4  Light-colored stool

    4  Hard or foul-smelling stool

    4  Pain on right side under your rib cage

    Total Score

    Please scroll up to the top and double check what you have completed and correct any errors before submitting PLEASE PRINT FORM CONFIMATION PAGE TO KEEP A COPY FOR YOUR SELF (BRING WITH YOU TO CONSULT)