For all the following check once for “some” and twice for “a lot”.
Chemical / Physiologic Stress:
I over or under eat O O
I have Incomplete digestion / acid indigestion O O
I have vitamin / mineral deficiencies O O
I have food sensitivities O O
I experience sleep cycle disturbance O O
I live or work in high traffic areas – low oxygen O O
I have allergies (i.e. pollens etc.) O O
I have environmental sensitivities O O
I have bacteria or virus infections O O
I have yeast and fungus infections O O
I have parasites O O
I have mercury fillings /Heavy metals O O
I use or am around pesticides O O
I take medications – Medical drug residues O O
I use recreational drugs O O
I use alcohol, tobacco O O
I am exposed to excess heat or cold O O
I drink treated city water O O
I use antiperspirants that contain aluminum O O
I use plug-in air fresheners O O
I use several medications – drug interactions O O
I have been Immunized O O
Diet Stress:
I use artificial food additives or sweeteners O O
I use fried foods – Rancid fats (free radicals) O O
I use packaged foods – Partially hydrogenated oils O O
I use vegetable/ seed/ polyunsaturated oils O O
I use sugary snacks (diabetes/ insulin resistance) O O
I use milk (hormone excessesand heart damage) O O
I use flour products (excitotoxins/ gut inflammation)O O
I use soy products (hormone imbalances) O O
I use MSG (brain damage causing) O O
I use salty snacks (hydration dysregulation) O O
I drink water with my meals (poor digestion) O O
I drink more than 1 serving of alcohol per day O O
I binge eat O O
I purge O O
I skip meals O O
I diet a lot O O
I skip eating my vegetables O O
I eat fast food (Contaminated food) O O
Psychological / Energetic Stresses:
1. Emotional Stresses:
Family issues / stress O O
Parenting-new & continuing O O
Work / bosses or co-workers O O
Money / taxes / etc. O O
Relationships (most aspects) O O
Past / regret or guilt O O
Future / worry / conjecture O O
Aging – too much or too little O O
Social stress / peer interactions O O
Self worth / esteem O O
Pursuit of love O O
Inappropriate anger O O
Excessive attention need O O
Death / loss / grief / divorce O O
Sudden change – good or bad O O
Fear / phobias / anxiety O O
Social order / ethics / politics O O
Sex and gender concerns O O
Addictions & using O O
Obsessive-compulsive behaviors O O
Survival concerns O O
Authority issues O O
Victim experience O O
Over concern for others O O
Dependency issues/ growing up O O
2. Mental Stresses:
Negative attitudes / beliefs /superstitions O O
Time & goal management issues O O
Need for control O O
Negative habits O O
Unrealistic expectations / immaturity O O
Information overload O O
Recent bad news / shock O O
Old unresolved traumas O O
Judging or being judged O O
Blocked expression O O
Subconscious / conscious inhibitions O O
Negative subconscious beliefs O O
Poor life skill development O O
Assumptions & faulty logic O O
Conflicting desires or wants O O
Poor boundaries / sense of self O O
Deficient assertiveness skills O O
False desire implantation-(advertising) O O
Negative imagery exposure-(violence on TV etc.) O O
3. Energetic Stresses:
Electro-magnetic pollution (EMFs) O O
Aesthetic deprivation (lack of beauty) O O
Radiation / sunburn O O
Insufficient natural light O O
Acoustic stress (sound or noise) O O
4. Spiritual Stresses:
Disharmony with life O O
Purpose & meaning missing O O
God’s will vs. ego self will O O
Non-acceptance of what is O O
Narcissism / self-centered O O
Attachment to right and wrong O O
No outflow to others O O
Failed connection / participation O O
Structural Functioning Stress:
Traumatic injury (i.e. a fall) O O
Whiplash injury O O
Over exertion / lifting stress O O
Repeated micro-trauma injury O O
Poor workstation ergonomics O O
Not enough exercise / excess sitting O O
Poor muscle tone O O
Balance / coordination problems O O
Joint pain affecting motion O O
Bad posture O O
Weak ligaments O O
Foot / knee problems O O
Subluxations of the spine O O
TMJ (jaw) dysfunction O O
Scars & adhesions O O
Bursitis / tendonitis /Disc inflammation O O
Diaphragm tension O O
Congested lymph glands O O
Stomach / bowel problems O O
Liver or kidney trouble O O
Sinus problems O O
Nerve irritation-inflammation O O
Impaired feeling sensation O O
Visual disturbances O O
Teeth and gum problems O O
Infections/ Overt disease conditions O O
Genetic disorders O O