Professional Documents
Culture Documents
2. Do you eat more packaged (frozen or canned) fruits and vegetables than fresh?
__ Yes (3) __ No (0)
7. Do you eat quick cook grains such as Rice-aroni, Quaker Oats or Minute rice
More often than slow cooked organic whole grains?
__Yes (5) __No (0)
8. Do you eat white bread more often than whole grain breads?
__Yes (5) __No (0)
10. Do you eat non-organic yogurts from the stores that are low fat,
Presweetened or have fruit added?
Yes (check option below) __No (0)
__1-2 times per week (1)
__3 times per week (3)
__more than 3 times per week (5)
11. Do you eat typical store bought eggs from cage raised chickens ( as opposed to
Free range, grain fed eggs)?
__Yes (5) __No (0)
12. Do you eat red meat more than once every four days?
__Yes(3) __No (0)
13. Do you commonly eat meats(beef, chicken, turkey) from sources other than a
Free-range and hormone-free source?
__ Yes (3) __ No (0)
14. Do you eat canned fish more frequently than fresh fish?
__Yes (3) __No (0)
17. Do you eat nuts and / or seeds that are roasted and / or salted?
__Yes (1) __No (0)
21. Do you eat TV dinners or other highly processed foods more than three times a
Week?
__Yes (5) __No (0)
22. Do you eat from fast food restaurants like McDonalds, Arbey’s Wendy’s etc…
__Yes (check option below) __No(0)
__1-2 times per week (2)
__3 times per week (5)
__more than 3 times per week (10)
25. Do you eat some form of store bought dessert, such as ice cream, cookies,
Donuts, cakes or pies after dinner most nights?
Yes (check option below) __No(0)
__once a week (1)
__2-3 times per week (3)
__more than 3 times per week (5)
STRESS
1. Do you eat more or less when stressed than when not stressed?
___ Yes (10) ___ No (0)
5. Do you often feel upset when things go wrong or feel that things go wrong often?
___ Yes (5) ___ No (0)
9. Have you had reduced contact from friends (feeling anti-social) or an increase in
contact because you feel you need to vent your frustrations or stresses to others?
___ Yes (3) ___ No (0)
12. Do you lose more than two days of work or school a year due to illness?
___ Yes (5) ___ No (0)
CIRCADIAN HEALTH
1. Do you live in the same time zone as you where born in?
___ Yes (0) ___ No (5)
5. Are the times you have bowel movements consistent and predictable on a daily
basis?
___ Yes (0) ___ No (5)
6. Do you suffer from reduced memory since moving to a new time zone or since
traveling across time zones?
7. Has your sense of hunger changed from being hungry at breakfast (upon rising) ,
lunch (mid-day) and dinner times (sunset) since moving to a new time zone or
traveling across time zones frequently?
___ Yes (10) ___ No (0)
8. Do you wake up at night between 1:00 am and 4:00 am and have a hard time
falling back to sleep?
Yes (check option below) ___ No (0)
___ once a week (1)
___ 3 times per week (5)
___ more than three times per week (10)
9. Do you have a hard time staying awake in the afternoon after eating lunch?
Yes (check option below) ___ No (0)
___ once a week (1)
___ 3 times per week (5)
___ more than three times per week (10)
10. Do you do shift work that requires you to stay up late at night?
___ Yes (10) ___ No (0)
TOTAL SCORE____
5. Do you frequently eat carbohydrates ( i.e. breads, bagels, cookies, pasta, fruit,
cereals, muffins, crackers, chocolate, or candy) by themselves?
___ Yes (5) ___ No (0)
6. Do you get hungry or crave sweets within two hours after eating a meal?
___ Yes (5) ___ No (0)
7. Do you use caffeine and / or sugar containing drinks (i.e. coffee, tea, sodas, fruit
juices with sucrose, corn syrup or added sugar)?
Yes (check option below) ___ No (0)
___ once a week (1)
___ 3 times per week (3)
___ more than three times per week (5)
9. Do you have difficulty burning fat around your belly, hips or thighs even with
regular exercise?
___ Yes (3) ___ No (0)
TOTAL SCORE____
6. Do you crave certain foods, such as bread, chocolate, certain fruit, and red meat,
if you have not eaten them in a day or two?
___ Yes (5) ___ No (0)
9. Do you frequently ( more than twice per week) experience abdominal pain,
cramps or general abdominal discomfort?
___ Yes (20) ___ No (0)
3. Have you ever been or are you being treated for any condition requiring that you
take medical drugs?
___ Yes (10) ___ No (0)
5. In general, do your bowel movements: sink, are they loose, hard and sink, hard to
pass or foul smelling?
___ Yes (10) ___ No (0)
6. Do you currently suffer from any digestive disorder such as irritable bowel
syndrome, Crone’s, inflammatory bowel disease, or frequently have pain in the
region above or below the naval?
___ Yes (10) ___ No (0)
8. Do you have two different kinds of metal in your mouth, such as gold and silver
or mercury amalgam and gold or silver?
___ Yes (10) ___ No (0)
10. Do you have or have you had dandruff in the past year?
___ Yes (10) ___ No (0)
11. Do you regularly eat or drink products containing sugar, white flour, processed
milk or dairy products?
___ Yes (5) ___ No (0)
12. Do you crave sugar, fruit or milk if you don’t have either of these items for more
than three days?
___ Yes (10) ___ No (0)
13. Do you find that regardless of how much you eat, you get hungry very quickly?
___ Yes (5) ___ No (0)
14. In the past year, have you experienced athletes foot ( itching around the toes, soles
or heel of the foot), jock itch, or have any fungal infection under a toenail (porus
thickening of the toenail)?
___ Yes (20) ___ No (0)
15. Do you ever get a reddening around the mouth or nose area after eating or
drinking one or more food items?
___ Yes (5) ___ No (0)
18. Do you snack on sweets or drink coffee, soda pop or sports drinks most days to
keep your energy up?
___ Yes (10) ___ No (0)
20. Have you ever had sex or close physical contact with anyone who you know who
had a fungal infection (including athletes foot, jock itch, dandruff) or parasite
infection?
___ Yes (20) ___ No (0)
TOTAL SCORE____
6. Are you sensitive to paint fumes, perfume, traffic fumes, detergents or cigarette
smoke?
Yes (check option below) ___ No (0)
___ mildly (3)
___ moderately (5)
___ very (10)
7. Have you been unable to lose cellulite with diet and/ or exercise?
___Yes (10) ___ No (0)
8. Are you currently, or have you in the past, been frequently exposed to industrial
or agricultural chemicals, such as solvents, cleaning fluids, paint fumes, plant
sprays and fertilizers?
Yes (check option below) ___ No (0)
___ brief exposure (3)
___ more than once a week (5)
___ daily (10)
10. Do you suffer from skin reactions such as rashes, itching, burning, for which the
cause is unknown?
Yes (check option below) ___ No (0)
___ 1-2 times per month (3)
___ 3 times per month (5)
___ more than three times per month (10)
TOTAL SCORE:_____
IMMUNE HEALTH
1. Were your scores in the red zone on two or more of the other questionnaires in
this trouble shooting section?
Yes (check option below) ___ No (0)
___ 2 questionnaires (5)
___ 3 questionnaires (10)
___ more than three questionnaires (15)
4. Have you been on antibiotics….and not been re-colonized, with friendly bacteria
supplementation?
___ Yes (10) ___ No (0)
5. How many days of work have you miss due to illness or doctor visits?
___ 0-1 day (0)
___ 2-4 days (5)
___ 5-7 days (10)
___ more than 10 days per year (20)
7. Do you drink or cook with water from the tap (city water containing chlorine)?
___ Yes (10) ___ No (0)
8. Do you work anywhere you can touch or smell industrial chemicals, cleaning
agents, solvents or any known toxic materials, such as farming pesticides,
janitorial supplies, engine cleaning solvents, paint thinners or paints, plastics
manufacturing, or live within two miles of a commercial farm, commercial golf
course, waste dump, industrial complex or have a neighbor that spays pesticide on
their yard; or use bug sprays in your home or yard, including anti-insect
insecticide?
___ Yes (10) ___ No (0)
9. Do you smoke cigarettes, drink more than one cup of coffee or artificially
sweetened beverages daily, or drink alcoholic beverages more than once a week?
___ Yes (10) ___ No (0)
11. Do you work with children (in a day care center or school) or in a medical
facility?
___ Yes (10) ___ No (0)
13. Do you get less than an average of eight hours of sleep each night?
___ Yes (10) ___ No (0)
14. Are you emotionally challenged or stressed due to any of the following:
a. Financial stress
b. Stressful relationship with a family member or with co workers
c. Religious belief system that may have been imposed upon you by parents,
other family members or close friends
d. A sexual relationship or lack there of
e. Being underweight, overweight, or obese
f. Feeling unfulfilled in your work life or daily life
15. Do you exercise at least three times a week for at least 20 minutes?
___Yes (0) ___No (10)
18. Do you exercise more than three times a week and experience any of the
following symptoms:
• Have a hard time warming up during your exercise sessions
• Nagging injury
• Get colds more than two times a year
• Problems with any form of infection, ear, eye, skin, or otherwise more
than once a year
• Reduced motivation
• Low back pain
___Yes (10) ___No (0)
20. Do you sleep with an electric blanket or have electrical appliances within eight
feet of your bed?
___Yes (10) ___No (0)
23. Do you have or have you had a yeast infection (Candida) in the past six months?
___Yes (20) ___No (0)
THYROID FUNCTION
2. Do you have a tendency toward excessive weight gain or inability to lose weight?
___Yes (10) ___No (0)
3. Do you experience low energy, fatigue, lethargy, need lots of sleep (>8 hours) or
have trouble getting going in the morning?
___Yes (10) ___No (0)
6. Do you have little red bumps on the back of your arms (from below your
shoulders)?
___Yes (10) ___No (0)
7. Is your hair dry, course, split, or falling out more than normal?
___Yes (5) ___No (0)
10. Do you experience swollen eyelids, puffiness in face and under eyes or general
water retention more than once a week?
___Yes (10) ___No (0)
1. Do you feel that you do not tolerate exercise well or feel worse after exercise?
___ Yes (10) ___ No (0)
8. In General do you feel that you have low energy, feel tired or fatigued during the
day?
___ Yes (5) ___ No (0)
9. Do you have the feeling of being mentally and emotionally over stressed?
___ Yes (10) ___ No (0)
10. Do you need caffeine ( coffee, tea or other stimulating drinks ) to get you going in
the morning?
Yes (check option below) ___ No (0)
___ 1-2 times per week (3)
___ 3 times per week (5)
___ more than 3 times per week (10)
TOTAL SCORE_____
WOMANS HEALTH
If you have PMS, it is likely that you will experience five or more of the
following symptoms while premenstrual, but not at other times during your cycle.
1. Depression, feelings of hopelessness or self-depreciating thoughts.
2. Marked anxiety, tension, feelings of being “ keyed up” or “on edge”
3. Feeling suddenly sad or tearful, increased sensitivity to rejection
4. Persistent and marked anger, irritability or increased interpersonal conflicts
5. Decreased interest in usual activities (i.e. work, school, friends, hobbies)
6. Difficulty concentrating
7. Tire quickly or marked lack of energy
8. Marked change in appetite, overeating or specific food cravings
9. Sleep more or less than usual
10. A sense of being overwhelmed or out of control
11. Physical symptoms such as breast tenderness or swelling, headaches, joint or
muscle pain, a sensation of bloating, weight gain
2. Have you experienced a change in the average length of your menstrual cycle in
the past year?
___ Yes (5) ___ No (0)
3. Have you noticed a change in symptoms experienced with your periods in the last
year?
Yes (check option below) ___ No (0)
___ becoming worse (1)
___ mildly worse (3)
___ moderate (5)
___ severe (10)
5. Have you experienced a change in your normal sleep patterns in the past year ( or
at any time if the pattern still persists and is less favorable than previously)?
___Yes (3) ___ No (0)
11. Have you been unable to flatten your abdominal wall through diet and/or exercise
since having one or more children?
___ Yes (5) ___ No (0)
13. Do you have any incontinence (trouble controlling urine, particularly during
physical activities such as running, lifting heavy objects or during an exercise
class or activity such as tennis)?
___ Yes (10) ___ No (0)
17. Do you currently, or in the past three months< have pain or a burning sensation
when urinating?
___ Yes (10) ___ No (0)
19. Are you constipated or do you have a hard time passing a bowel movement?
Yes (check option below) ___ No (0)
___ 1-2 times a week (3)
___ more than 3 times per week (5)
Note: If you don’t pass 12 inches of bowel movement, have a bowel movement
after each meal, or if you feel like you are not fully eliminating your bowel each
time, you are most likely constipated.
20. Do you ever have kidney pain (pain in region between your bottom rib and belt
line)?
Yes (check option below) ___ No (0)
___ 1-2 times a month (3)
___ once a week (5)
___ more than once a week (10)
21. Do you currently, or in the last three months, have painful menstruation?
___ Yes (10) ___ No (0)
TOTAL SCORE:_____
MEN’S HEALTH
4. Do you suffer from backache, joint pains or stiffness of the body in general?
Yes (check option below) ___ No (0)
___ once a month (1)
___ twice a month (3)
___ weekly (5)
*Note: If you are not waking up with an erection and sexual urge, this is an
indicator of stress in the male. It is also an indicator of circadian stress; please be
sure to complete the circadian health questionnaire.
9. Have you had testicular trauma in your life, such as a blow to the testicles in a
sporting event?
___ Yes (5) ___ No (0)
11. Have you noticed an increase in fat around the belly button region in concert with
four or more symptoms on this questionnaire or since turning 35?
Yes (check option below) ___ No (0)
___ 1inch more (3)
___ 2 inches more (5)
___ more than 2 inches (10)
12. Do you have problems with your prostate? If you experience any two of the
following answer “Yes” to this question.
• Difficulty starting your urine stream
• Decrease strength and force of your urine stream
• Urinating more frequently than normal for you
• Feeling as if your bladder isn’t empty, even after you just finished urinating
• Dribbling after you have just finished urinating
• Frequently have an urge or need to urinate
• Blood in your urine ( make sure that you have not eaten beets in the past 72
hours before mistaking it for blood)
• Painful ejaculation
• Pain or burning sensation while urinating
• Tenderness or pain in the pelvis region, particularly when associated with hip or
low back pain
• Pain or swelling in testicles
___ Yes (10) ___ No (0)
13. Have you noticed a reduction in strength in concert with four or more symptoms
in this questionnaire or since turning 35?
___ Yes (5) ___ No (0)
14. Have you experienced a reduction in muscle mass in concert with four or more
other symptoms in this questionnaire or since turning 35?
Yes (check option below) ___ No (0)
___ Butt only (3)
___ abdominals and butt (5)
___ abdominals, butt, and shoulders (10)
TOTAL SCORE____
STEP #1 - Please Record Your Answers Here:
1. You Are What You Eat ____________
2. Stress _____________
5. Detoxification ____________
STEP #2 - If you want to know what the heck these scores mean...
make sure you are on the Lean Hybrid Muscle e mail list
and keep an look out for an e mail titled
Thanks,
Elliott Hulse :)