Functional Medicine AssessmentStep 1 of 425%New Patient PaperworkName(Required) First Last Email(Required) Phone(Required)Date Of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Weight (LB)(Required)Your weight in poundsHeight (Ft)(Required)Your height in feetWho are you seeing?(Required) Cara Olsen Haley Surface Anissa LosemanSex(Required) Male FemaleMain Reason For Visit(Required)Please describe the main purpose of your visit and list your top 3 objectives.Body Systems AssessmentList the five main physical complaints you have in order of their importance *(Required)0 = Not applicable 1 = Mild symptoms (occurs rarely) 2 = MODERATE symptoms (occurs several times a month) 3 = SEVERE symptoms (occurs almost constantly)Group 1Acid foods upset(Required) 0 1 2 3Get chilled, often(Required) 0 1 2 3Lump in throat(Required) 0 1 2 3Dry mouth-eyes-nose(Required) 0 1 2 3Pulse speeds after meal(Required) 0 1 2 3Keyed up - fail to calm(Required) 0 1 2 3Cuts heal slowly(Required) 0 1 2 3Gag Easily(Required) 0 1 2 3Unable to relax, startles easily(Required) 0 1 2 3Extremities cold, clammy(Required) 0 1 2 3Strong light irritates(Required) 0 1 2 3Urine amount reduced(Required) 0 1 2 3Heart pounds after retiring(Required) 0 1 2 3Nervous stomach(Required) 0 1 2 3Appetite reduced(Required) 0 1 2 3Cold sweats often(Required) 0 1 2 3Fever easily raised(Required) 0 1 2 3Neuralgia-like pains(Required) 0 1 2 3Staring, blinks little(Required) 0 1 2 3Sour stomach frequent(Required) 0 1 2 3Group 2Joint stiffness after arising(Required) 0 1 2 3Muscle-leg-toe cramps at night(Required) 0 1 2 3Butterfly stomach cramps(Required) 0 1 2 3Eyes or nose watery(Required) 0 1 2 3Eyes blink often(Required) 0 1 2 3Eyelids swollen, puffy(Required) 0 1 2 3Indigestion soon after meals(Required) 0 1 2 3Always seem hungry; feels 'lightheaded' often(Required) 0 1 2 3Digestion rapid(Required) 0 1 2 3Vomiting frequent(Required) 0 1 2 3Hoarseness frequent(Required) 0 1 2 3Breathing irregular(Required) 0 1 2 3Pulse slow; feels(Required) 0 1 2 3Gagging reflex slow(Required) 0 1 2 3Difficulty swallowing(Required) 0 1 2 3Constipation, diarrhea alternating(Required) 0 1 2 3Slow starter(Required) 0 1 2 3Get chilled infrequently(Required) 0 1 2 3Perspire easily(Required) 0 1 2 3Circulation poor, sensitive to cold(Required) 0 1 2 3Subject to colds, asthma, bronchitis(Required) 0 1 2 3Group 3Eat when nervous(Required) 0 1 2 3Excessive appetite(Required) 0 1 2 3Hungry between meals(Required) 0 1 2 3Irritable before meals(Required) 0 1 2 3Get shaky if hungry(Required) 0 1 2 3Fatigue, eating relieves(Required) 0 1 2 3Lightheaded if meals delayed(Required) 0 1 2 3Heart palpitates if meals missed or delayed(Required) 0 1 2 3Afternoon headaches(Required) 0 1 2 3Overeating sweets upsets(Required) 0 1 2 3Awaken after few hours sleep - hard to get back to sleep(Required) 0 1 2 3Crave candy or coffee in afternoons(Required) 0 1 2 3Moods of depression - blues or melancholy(Required) 0 1 2 3Abnormal craving for sweets or snacks(Required) 0 1 2 3Group 4Hands and feet go to sleep easily, numbness(Required) 0 1 2 3Sigh frequently, air hunger(Required) 0 1 2 3Aware of breathing heavily(Required) 0 1 2 3High altitude discomfort(Required) 0 1 2 3Opens windows in closed room(Required) 0 1 2 3Susceptible to colds and fevers(Required) 0 1 2 3Afternoon yawner(Required) 0 1 2 3Get drowsy often(Required) 0 1 2 3Swollen ankles worse at night(Required) 0 1 2 3Muscle cramps, worse during exercise; get charlie horses(Required) 0 1 2 3Shortness of breath on exertion(Required) 0 1 2 3Dull pain in chest or radiating into left arm, worse on exertion(Required) 0 1 2 3Bruise easily, black and blue spots(Required) 0 1 2 3Tendency to anemia(Required) 0 1 2 3Nose bleeds frequent(Required) 0 1 2 3Noises in head, or ringing in ears(Required) 0 1 2 3Tensions under breastbone, or feeling of tightness(Required) 0 1 2 3Group FiveDizziness(Required) 0 1 2 3Dry Skin(Required) 0 1 2 3Burning feet(Required) 0 1 2 3Blurred Vision(Required) 0 1 2 3Itching skin and feet(Required) 0 1 2 3Excessive falling hair(Required) 0 1 2 3Frequent skin rashes(Required) 0 1 2 3Bitter, metallic taste in mouth in mornings(Required) 0 1 2 3Bowel movements painful or difficult(Required) 0 1 2 3Worrier, feels insecure(Required) 0 1 2 3Feeling queasy; headache over eyes(Required) 0 1 2 3Greasy foods upset(Required) 0 1 2 3Stools light-colored(Required) 0 1 2 3Skin peels on foot soles(Required) 0 1 2 3Pain between shoulder blades(Required) 0 1 2 3Use laxatives(Required) 0 1 2 3Stools alternate from soft to watery(Required) 0 1 2 3History of gallbladder attacks or gallstones(Required) 0 1 2 3Sneezing attacks(Required) 0 1 2 3Dreaming, nightmare type bad dreams(Required) 0 1 2 3Bad breathe (halitosis)(Required) 0 1 2 3Milk products cause distress(Required) 0 1 2 3Sensitive to hot weather(Required) 0 1 2 3Burning or itching anus(Required) 0 1 2 3Crave sweets(Required) 0 1 2 3Group SixLoss of taste for meat(Required) 0 1 2 3Lower bowel gas several hours after eating(Required) 0 1 2 3Burning stomach sensations, eating relieves(Required) 0 1 2 3Coated tongue(Required) 0 1 2 3Pass large amounts of foul-smelling gas *(Required) 0 1 2 3Indigestion 1/2 - 1 hour after(Required) 0 1 2 3Mucous colitis or irritable bowel(Required) 0 1 2 3Gas shortly after eating(Required) 0 1 2 3Stomach bloat with eating, may be up to 3-4 hours after(Required) 0 1 2 3Group Seven (A)Insomnia(Required) 0 1 2 3Nervousness(Required) 0 1 2 3Can't gain weight(Required) 0 1 2 3Intolerance to heat(Required) 0 1 2 3Highly emotional(Required) 0 1 2 3Flush easily(Required) 0 1 2 3Night sweats(Required) 0 1 2 3Thin, moist skin(Required) 0 1 2 3Inward trembling(Required) 0 1 2 3Heart palpitates(Required) 0 1 2 3Increased appetite without weight gain(Required) 0 1 2 3Pulse fast at rest(Required) 0 1 2 3Eyelids and face twitch(Required) 0 1 2 3Irritable and restless(Required) 0 1 2 3Can't work under pressure(Required) 0 1 2 3Group Seven (B)Increase in weight(Required) 0 1 2 3Decrease in appetite(Required) 0 1 2 3Fatigue easily(Required) 0 1 2 3Ringing in ears(Required) 0 1 2 3Sensitive to cold(Required) 0 1 2 3Dry or scaly skin(Required) 0 1 2 3Sleepy during day(Required) 0 1 2 3Constipation(Required) 0 1 2 3Mental sluggishness(Required) 0 1 2 3Hair coarse, falls out(Required) 0 1 2 3Headaches upon arising wear off during day(Required) 0 1 2 3Slow pulse, below 65(Required) 0 1 2 3Frequency of urination(Required) 0 1 2 3Impaired hearing(Required) 0 1 2 3Reduced initiative(Required) 0 1 2 3Group Seven (C)Failing memory(Required) 0 1 2 3Low blood pressure(Required) 0 1 2 3Increased sex drive(Required) 0 1 2 3Headaches, splitting or rendering type(Required) 0 1 2 3Decreased sugar tolerance(Required) 0 1 2 3Group Seven (D)Abnormal thirst(Required) 0 1 2 3Bloating of abdomen(Required) 0 1 2 3Weight gain around hips or waist(Required) 0 1 2 3Sex drive reduced or lacking(Required) 0 1 2 3Tendency to ulcers, colitis(Required) 0 1 2 3Increased sugar tolerance(Required) 0 1 2 3Women: menstrual disorders(Required) 0 1 2 3Young girls: lack of menstrual function(Required) 0 1 2 3Group Seven (E)Dizziness(Required) 0 1 2 3Headaches(Required) 0 1 2 3Hot flashes(Required) 0 1 2 3Increased blood pressure(Required) 0 1 2 3Hair growth on face or body (female)(Required) 0 1 2 3Sugar in urine (not diabetes)(Required) 0 1 2 3Masculine tendencies (female)(Required) 0 1 2 3Group Seven (F)Weakness, dizziness(Required) 0 1 2 3Chronic fatigue(Required) 0 1 2 3Low blood pressure(Required) 0 1 2 3Nails, weak, ridged(Required) 0 1 2 3Tendency to hives(Required) 0 1 2 3Arthritic tendencies(Required) 0 1 2 3Perspiration increase(Required) 0 1 2 3Bowel disorders(Required) 0 1 2 3Poor circulation(Required) 0 1 2 3Swollen ankles(Required) 0 1 2 3Crave salt(Required) 0 1 2 3Brown spots or bronzing of skin(Required) 0 1 2 3Allergies - tendency to asthma(Required) 0 1 2 3Weakness after colds, influenza(Required) 0 1 2 3Exhaustion - muscular and nervous(Required) 0 1 2 3Respiratory disorders(Required) 0 1 2 3Group EightMuscle weakness(Required) 0 1 2 3Lack of stamina(Required) 0 1 2 3Drowsiness after eating(Required) 0 1 2 3Muscular soreness(Required) 0 1 2 3Rapid heart beat(Required) 0 1 2 3Hyper-irritable(Required) 0 1 2 3Feeling of a band around your head(Required) 0 1 2 3Melancholia (feeling of sadness)(Required) 0 1 2 3Swelling of ankles(Required) 0 1 2 3Diminished Urination(Required) 0 1 2 3Tendency to consume sweets or carbs(Required) 0 1 2 3Muscular Spasms(Required) 0 1 2 3Blurred vision(Required) 0 1 2 3Loss of muscular control(Required) 0 1 2 3Numbness(Required) 0 1 2 3Night sweats(Required) 0 1 2 3Rapid digestion(Required) 0 1 2 3Sensitivity to noise(Required) 0 1 2 3Redness of palms of hands and bottom of feet(Required) 0 1 2 3Visible veins on chest and abdomen(Required) 0 1 2 3Hemorrhoids(Required) 0 1 2 3Apprehension (feeling that something bad is going to happen)(Required) 0 1 2 3Nervousness causing loss of appetite(Required) 0 1 2 3Nervousness with indigestion(Required) 0 1 2 3Gastritis(Required) 0 1 2 3Forgetfulness(Required) 0 1 2 3Thinning hair(Required) 0 1 2 3FEMALE ONLYVery easily fatigued 0 1 2 3Premenstrual tension 0 1 2 3Painful menses 0 1 2 3Menstruation excessive and prolonged 0 1 2 3Painful breasts 0 1 2 3Menstruate too frequently 0 1 2 3Vaginal Discharge 0 1 2 3Hysterectomy / ovaries removed 0 1 2 3Menopausal hot flashes 0 1 2 3Menses scanty or missed 0 1 2 3Acne, worse at menses 0 1 2 3Depression of long standing 0 1 2 3MALE ONLYProstate trouble 0 1 2 3Urination difficult or dribbling 0 1 2 3Night urination frequent 0 1 2 3Depression 0 1 2 3Pain on inside of legs or heels 0 1 2 3Feeling of incomplete bowel evacuation 0 1 2 3Lack of energy 0 1 2 3Migrating aches and pains 0 1 2 3Tired too easily 0 1 2 3Avoids activity 0 1 2 3Leg nervousness at night 0 1 2 3Diminished sex drive 0 1 2 3Brain Health & Nutrition AssessmentSelect the appropriate choice for each question. 0 almost never happens 1 rarely happens 2 sometimes happens 3 almost always happensSection 1Low brain endurance for focus and concentration(Required) 0 1 2 3Cold hands and feet(Required) 0 1 2 3Must exercise or drink coffee to improve brain function(Required) 0 1 2 3Poor nail health(Required) 0 1 2 3Fungal growth on toenails(Required) 0 1 2 3Must wear socks at night(Required) 0 1 2 3Nail beds are white instead of pink(Required) 0 1 2 3The tip of the nose is cold(Required) 0 1 2 3Section 2Irritable, nervous, shaky, or light-headed between meals(Required) 0 1 2 3Feel energized after meals(Required) 0 1 2 3Difficulty eating large meals in the morning(Required) 0 1 2 3Energy level drops in the afternoon(Required) 0 1 2 3Crave sugar and sweets in the afternoon(Required) 0 1 2 3Wake up in the middle of the night(Required) 0 1 2 3Difficulty concentrating before eating(Required) 0 1 2 3Depend on coffee to keep going(Required) 0 1 2 3Section 3Fatigue after meals(Required) 0 1 2 3Sugar and sweet cravings after meals(Required) 0 1 2 3Need for a stimulant, such as coffee, after meals(Required) 0 1 2 3Difficulty losing weight(Required) 0 1 2 3Increased frequency of urination(Required) 0 1 2 3Difficulty falling asleep(Required) 0 1 2 3Increased Appetite(Required) 0 1 2 3Section 4Always have projects and things that need to be done(Required) 0 1 2 3Never have time for yourself(Required) 0 1 2 3Not getting enough sleep or rest(Required) 0 1 2 3Difficulty getting regular exercise(Required) 0 1 2 3Feel that you are not accomplishing your life's purpose(Required) 0 1 2 3Section 5Dry and unhealthy skin(Required) 0 1 2 3Dandruff or a flaky scalp(Required) 0 1 2 3Consumption of processed foods that are bagged or boxed(Required) 0 1 2 3Consumption of fried foods(Required) 0 1 2 3Difficulty consuming raw nuts or seeds(Required) 0 1 2 3Difficulty consuming fish (not fried)(Required) 0 1 2 3Difficulty consuming olive oil, avocados, flax seed oil, or natural fats(Required) 0 1 2 3Section 6Difficulty digesting foods(Required) 0 1 2 3Constipation or inconsistent bowel movements(Required) 0 1 2 3Increased bloating or gas(Required) 0 1 2 3Abdominal distention after meals(Required) 0 1 2 3Difficulty digesting protein-rich foods(Required) 0 1 2 3Difficulty digesting fatty or greasy foods(Required) 0 1 2 3Difficulty swallowing supplements or large bites of food(Required) 0 1 2 3Abnormal gag reflex(Required) Yes NoSection 7Brain fog (unclear thoughts or concentration)(Required) Yes NoPain and inflammation(Required) Yes NoNoticeable variations in mental speed(Required) Yes NoBrain fatigue after meals(Required) 0 1 2 3Brain fatigue after exposure to chemicals, scents, or pollutants(Required) 0 1 2 3Brain fatigue when the body is inflamed(Required) 0 1 2 3Section 8Grain consumption leads to tiredness(Required) 0 1 2 3Grain consumption makes it difficult to focus and concentrate(Required) 0 1 2 3Feel better when bread and grains are avoided(Required) 0 1 2 3Grain consumption causes the development of any symptoms(Required) 0 1 2 3A 100% gluten-free diet(Required) Yes NoSection 9A diagnosis of celiac disease, gluten sensitivity, hypothyroidism, or an autoimmune disease(Required) Yes NoFamily members who have been diagnosed with an autoimmune disease(Required) Yes NoFamily members who have been diagnosed with celiac disease or gluten sensitivity(Required) Yes NoChanges in brain function with stress, poor sleep, or immune activation(Required) 0 1 2 3Section 10A loss of pleasure in hobbies and interests(Required) 0 1 2 3Feel overwhelmed with ideas to manage(Required) 0 1 2 3Feelings of inner rage or unprovoked anger(Required) 0 1 2 3Feelings of paranoia(Required) 0 1 2 3Feelings of sadness for no reason(Required) 0 1 2 3A loss of enjoyment in life(Required) 0 1 2 3A lack of artistic appreciation(Required) Yes NoFeelings of sadness in overcast weather(Required) 0 1 2 3A loss of enthusiasm for favorite activities(Required) 0 1 2 3A loss of enjoyment in favorite foods(Required) 0 1 2 3A loss of enjoyment in friendships and relationships(Required) 0 1 2 3Inability to fall into deep, restful sleep(Required) 0 1 2 3Feelings of dependency on others(Required) 0 1 2 3Feelings of susceptibility to pain(Required) 0 1 2 3Section 11Feelings of worthlessness(Required) 0 1 2 3Feelings of hopelessness(Required) 0 1 2 3Self-destructive thoughts(Required) 0 1 2 3Inability to handle stress(Required) 0 1 2 3Anger and aggression while under stress(Required) 0 1 2 3Feelings of tiredness, even after many hours of sleep(Required) 0 1 2 3A desire to isolate yourself from others(Required) 0 1 2 3An unexplained lack of concern for family and friends(Required) 0 1 2 3An inability to finish tasks(Required) 0 1 2 3Feelings of anger from minor reasons(Required) 0 1 2 3Section 12A decrease in visual memory (shapes and images)(Required) Yes NoA decrease in verbal memory(Required) 0 1 2 3Occurrence of memory lapses(Required) 0 1 2 3A decrease in creativity(Required) 0 1 2 3A decrease in comprehension(Required) 0 1 2 3Difficulty calculating numbers(Required) 0 1 2 3Difficulty recognizing objects and faces(Required) 0 1 2 3A change in opinion about yourself(Required) 0 1 2 3A decrease in mental alertness(Required) 0 1 2 3Section 13Slow mental recall(Required) 0 1 2 3A decrease in mental speed(Required) 0 1 2 3A decrease in concentration quality(Required) 0 1 2 3Slow cognitive processing(Required) 0 1 2 3Impaired mental performance(Required) 0 1 2 3An increase in the ability to be distracted(Required) 0 1 2 3Need coffee or caffeine sources to improve mental function(Required) 0 1 2 3Section 14Feelings of nervousness or panic for no reason(Required) 0 1 2 3Feelings of dread(Required) 0 1 2 3Feelings of a knot in your stomach(Required) 0 1 2 3Feelings of being overwhelmed for no reason(Required) 0 1 2 3Feelings of guilt about everyday decisions(Required) 0 1 2 3A restless mind(Required) 0 1 2 3An inability to turn off the mind when relaxing(Required) 0 1 2 3Disorganized attention(Required) 0 1 2 3Worry over things never thought about before(Required) 0 1 2 3Feelings of inner tension and inner excitability(Required) 0 1 2 3Stress AssessmentList any significant life events or changes in the last 3 months: (illness, injury, job change, new baby, marriage, divorce, extreme training for a sporting event, major project at work, etc)? *(Required)Hours of sleep each night(Required) 3-4 5-6 7-8 9+Alcoholic drinks per week:(Required) 0 1-2 3-5 6+Meals eaten out per week:(Required) 0 1-2 3-5 6+Do you have any downtime or participate in quiet mindfulness activities? (Pilates, yoga, meditation, quiet walks, personal hobbies)(Required) Yes NoSelect the appropriate choice for each question based on your experience within the LAST MONTH. 1 Not at all 2 Little bit 3 Somewhat 4 Quite a bit 5 Very MuchHow stressful would you say your life is?(Required) 1 2 3 4 5Dealing with daily stresses is negatively affecting my daily tasks(Required) 1 2 3 4 5I have a high intake of sugar and/or processed foods(Required) 1 2 3 4 5I feel worn down and/or burnt out(Required) 1 2 3 4 5I need caffeine or other energy drinks in the morning or afternoon to give me energy(Required) 1 2 3 4 5I seem to have lower than usual energy during the day.(Required) 1 2 3 4 5I experience body aches and pains.(Required) 1 2 3 4 5I have periods of low moods.(Required) 1 2 3 4 5I feel more irritable.(Required) 1 2 3 4 5My weight and metabolism have changed.(Required) 1 2 3 4 5I can't seem to focus or concentrate.(Required) 1 2 3 4 5I have feelings of anxiousness.(Required) 1 2 3 4 5I feel totally exhausted most of the day and only have a few productive hours.(Required) 1 2 3 4 5I find myself pushing through fatigue to get things done.(Required) 1 2 3 4 5I seem to be sleeping alot but never feel quite rested. I wake up feeling tired.(Required) 1 2 3 4 5I have difficulty getting to sleep and/or wake up in the middle of the night.(Required) 1 2 3 4 5I experience strong cravings for sweet or salty foods.(Required) 1 2 3 4 5I feel overwhelmed with daily tasks and all that is on my plate.(Required) 1 2 3 4 5I have a low sex drive.(Required) 1 2 3 4 5I am unable to enjoy socializing with family and/or friends.(Required) 1 2 3 4 5Total StressLow Stress (20-40): Stress is fairly well managed in your life. It may be important to support your body to continue its healthy response. Medium Stress (41-79): Your body's response to stress may be getting in the way of normal activities quite frequently, leaving you feeling depleted. Consult your health care professional for an individualized program to achieve your health goals. High Stress: (80-100) You may have experienced prolonged stress, and your body's stress response can no longer adapt or successfully cope. Consult your health care professional for targeted support and strategies for improvement.