Brain Health and Nutrition

Please check the appropriate number “0-3” on all questions below. Mark 0 for the least/never up to 3 as the most/always, unless otherwise specified.

SECTION 1

(Least/Never)  01 23  (Most/Always)

• Low brain endurance for focus and concentration
  • 0
  • 1
  • 2
  • 3
    
• Cold hands and feet
  • 0
  • 1
  • 2
  • 3
    
• Must exercise or drink coffee to improve brain function
  • 0
  • 1
  • 2
  • 3
    
• Poor nail health
  • 0
  • 1
  • 2
  • 3
    
• Fungal growth on toenails
  • 0
  • 1
  • 2
  • 3
    
• Must wear socks at night
  • 0
  • 1
  • 2
  • 3
    
• Nail beds are white instead of pink
  • 0
  • 1
  • 2
  • 3
    
• The tip of the nose is cold
  • 0
  • 1
  • 2
  • 3
    

SECTION 2

(Least/Never)  01 23  (Most/Always)

• Irritable, nervous, shaky, or light-headed between meals
  • 0
  • 1
  • 2
  • 3
    
• Feel energized after meals
  • 0
  • 1
  • 2
  • 3
    
• Difficulty eating large meals in the morning
  • 0
  • 1
  • 2
  • 3
    
• Energy level drops in the afternoon
  • 0
  • 1
  • 2
  • 3
    
• Crave sugar and sweets in the afternoon
  • 0
  • 1
  • 2
  • 3
    
• Wake up in the middle of the night
  • 0
  • 1
  • 2
  • 3
    
• Difficulty concentrating before eating
  • 0
  • 1
  • 2
  • 3
    
• Depend on coffee to keep going
  • 0
  • 1
  • 2
  • 3
    

SECTION 3

(Least/Never)  01 23  (Most/Always)

• Fatigue after meals
  • 0
  • 1
  • 2
  • 3
    
• Sugar and sweet cravings after meals
  • 0
  • 1
  • 2
  • 3
    
• Need for a stimulant, such as coffee, after meals
  • 0
  • 1
  • 2
  • 3
    
• Difficulty losing weight
  • 0
  • 1
  • 2
  • 3
    
• Increased frequency of urination
  • 0
  • 1
  • 2
  • 3
    
• Difficulty falling asleep
  • 0
  • 1
  • 2
  • 3
    
• Increased appetite
  • 0
  • 1
  • 2
  • 3
    

SECTION 4

(Least/Never)  01 23  (Most/Always)

• Always have projects and things that need to be done
  • 0
  • 1
  • 2
  • 3
    
• Never have time for yourself
  • 0
  • 1
  • 2
  • 3
    
• Not getting enough sleep or rest
  • 0
  • 1
  • 2
  • 3
    
• Difficulty getting regular exercise
  • 0
  • 1
  • 2
  • 3
    
• Feel that you are not accomplishing your life's purpose
  • 0
  • 1
  • 2
  • 3
    

SECTION 5

(Least/Never)  01 23  (Most/Always)

• Dry and unhealthy skin
  • 0
  • 1
  • 2
  • 3
    
• Dandruff or a flaky scalp
  • 0
  • 1
  • 2
  • 3
    
• Consumption of processed foods that are bagged or boxed
  • 0
  • 1
  • 2
  • 3
    
• Consumption of fried foods
  • 0
  • 1
  • 2
  • 3
    
• Difficulty consuming raw nuts or seeds
  • 0
  • 1
  • 2
  • 3
    
• Difficulty consuming fish (not fried)
  • 0
  • 1
  • 2
  • 3
    
• Difficulty consuming olive oil. avocados,flax seed oil. or natural fats
  • 0
  • 1
  • 2
  • 3
    

SECTION 6

(Least/Never)  01 23  (Most/Always)

• Difficulty digesting foods
  • 0
  • 1
  • 2
  • 3
    
• Constipation or inconsistent bowel movements
  • 0
  • 1
  • 2
  • 3
    
• Increased bloating or gas
  • 0
  • 1
  • 2
  • 3
    
• Abdominal distention after meals
  • 0
  • 1
  • 2
  • 3
    
• Difficulty digesting protein-rich foods
  • 0
  • 1
  • 2
  • 3
    
• Difficulty digesting starch-rich foods
  • 0
  • 1
  • 2
  • 3
    
• Difficulty digesting fatty or greasy foods
  • 0
  • 1
  • 2
  • 3
    
• Difficulty swallowing supplements or large bites of food
  • 0
  • 1
  • 2
  • 3
    
• Abnormal gag reflex
  • 0
  • 1
  • 2
  • 3
    

SECTION 7

(Least/Never)  01 23  (Most/Always)

• Brain fog (unclear thoughts or concentration)
  • 0
  • 1
  • 2
  • 3
    
• Pain and inflammation
  • 0
  • 1
  • 2
  • 3
    
• Noticeable variations in mental speed
  • 0
  • 1
  • 2
  • 3
    
• Brain fatigue after meals
  • 0
  • 1
  • 2
  • 3
    
• Brain fatigue after exposure to chemicals, scents, or pollutants
  • 0
  • 1
  • 2
  • 3
    
• Brain fatigue when the body is inflamed
  • 0
  • 1
  • 2
  • 3
    

SECTION 8

(Least/Never)  01 23  (Most/Always)

• Grain consumption leads to tiredness
  • 0
  • 1
  • 2
  • 3
    
• Grain consumption makes it difficult to focus and concentrate
  • 0
  • 1
  • 2
  • 3
    
• Feel better when bread and grains are avoided
  • 0
  • 1
  • 2
  • 3
    
• Grain consumption causes the development of any symptoms
  • 0
  • 1
  • 2
  • 3
    
• A 100% gluten-free diet
  • 0
  • 1
  • 2
  • 3
    

SECTION 9

(Least/Never)  01 23  (Most/Always)

• A diagnosis of celiac disease, gluten sensitivity,hypothyroidism, or an autoimmune disease
  • 0
  • 1
  • 2
  • 3
    
• Family members who have been diagnosed with an autoimmune disease
  • 0
  • 1
  • 2
  • 3
    
• Family members who have been diagnosed with celiac disease or gluten sensitivity
  • 0
  • 1
  • 2
  • 3
    
• Changes in brain function with stress, poor sleep, or immune activation
  • 0
  • 1
  • 2
  • 3
    

SECTION 10

(Least/Never)  01 23  (Most/Always)

• A loss of pleasure in hobbies and interests
  • 0
  • 1
  • 2
  • 3
    
• Feel overwhelmed with ideas to manage
  • 0
  • 1
  • 2
  • 3
    
• Feelings of inner rage or unprovoked anger
  • 0
  • 1
  • 2
  • 3
    
• Feelings of paranoia
  • 0
  • 1
  • 2
  • 3
    
• Feelings of sadness for no reason
  • 0
  • 1
  • 2
  • 3
    
• A loss of enjoyment in life
  • 0
  • 1
  • 2
  • 3
    
• A lack of artistic appreciation
  • 0
  • 1
  • 2
  • 3
    
• Feelings of sadness in overcast weather
  • 0
  • 1
  • 2
  • 3
    
• A loss of enthusiasm for favorite activities
  • 0
  • 1
  • 2
  • 3
    
• A loss of enjoyment in favorite foods
  • 0
  • 1
  • 2
  • 3
    
• A loss of enjoyment in friendships and relationships
  • 0
  • 1
  • 2
  • 3
    
• Inability to fall into deep, restful sleep
  • 0
  • 1
  • 2
  • 3
    
• Feelings of dependency on others
  • 0
  • 1
  • 2
  • 3
    
• Feelings of susceptibility to pain
  • 0
  • 1
  • 2
  • 3
    

SECTION 11

(Least/Never)  01 23  (Most/Always)

• Feelings of worthlessness
  • 0
  • 1
  • 2
  • 3
    
• Feelings of hopelessness
  • 0
  • 1
  • 2
  • 3
    
• Self-destructive thoughts
  • 0
  • 1
  • 2
  • 3
    
• Inability to handle stress
  • 0
  • 1
  • 2
  • 3
    
• Anger and aggression while under stress
  • 0
  • 1
  • 2
  • 3
    
• Feelings of tiredness, even after many hours of sleep
  • 0
  • 1
  • 2
  • 3
    
• A desire to isolate yourself from others
  • 0
  • 1
  • 2
  • 3
    
• An unexplained lack of concern for family and friends
  • 0
  • 1
  • 2
  • 3
    
• An inability to finish tasks
  • 0
  • 1
  • 2
  • 3
    
• Feelings of anger for minor reasons
  • 0
  • 1
  • 2
  • 3
    

SECTION 12

(Least/Never)  01 23  (Most/Always)

• A decrease in visual memory (shapes and images)
  • 0
  • 1
  • 2
  • 3
    
• A decrease in verbal memory
  • 0
  • 1
  • 2
  • 3
    
• Occurrence of memory lapses
  • 0
  • 1
  • 2
  • 3
    
• A decrease in creativity
  • 0
  • 1
  • 2
  • 3
    
• A decrease in comprehension
  • 0
  • 1
  • 2
  • 3
    
• Difficulty calculating numbers
  • 0
  • 1
  • 2
  • 3
    
• Difficulty recognizing objects and faces
  • 0
  • 1
  • 2
  • 3
    
• A change in opinion about yourself
  • 0
  • 1
  • 2
  • 3
    
• Slow mental recall
  • 0
  • 1
  • 2
  • 3
    

SECTION 13

(Least/Never)  01 23  (Most/Always)

• A decrease in mental alertness
  • 0
  • 1
  • 2
  • 3
    
• A decrease in mental speed
  • 0
  • 1
  • 2
  • 3
    
• A decrease in concentration quality
  • 0
  • 1
  • 2
  • 3
    
• Slow cognitive processing
  • 0
  • 1
  • 2
  • 3
    
• Impaired mental performance
  • 0
  • 1
  • 2
  • 3
    
• An increase in the ability to be distracted
  • 0
  • 1
  • 2
  • 3
    
• Need coffee or caffeine sources to improve
  • 0
  • 1
  • 2
  • 3
    

SECTION 14

(Least/Never)  01 23  (Most/Always)

• Feelings of nervousness or panic for no reason
  • 0
  • 1
  • 2
  • 3
    
• Feelings of dread
  • 0
  • 1
  • 2
  • 3
    
• Feelings of a “knot” in your stomach
  • 0
  • 1
  • 2
  • 3
    
• Feelings of being overwhelmed for no reason
  • 0
  • 1
  • 2
  • 3
    
• Feelings of guilt about everyday decisions
  • 0
  • 1
  • 2
  • 3
    
• A restless mind
  • 0
  • 1
  • 2
  • 3
    
• An inability to turn off the mind when relaxing
  • 0
  • 1
  • 2
  • 3
    
• Disorganized attention
  • 0
  • 1
  • 2
  • 3
    
• Worry over things never thought about before
  • 0
  • 1
  • 2
  • 3
    
• Feelings of inner tension and inner excitability
  • 0
  • 1
  • 2
  • 3