Cell Blueprint Assessment

Please read this section carefully before you fill out the form

It's best and faster to use a PC to fill in this questionnaire rather than a phone. The questionnaire will take approximately 30 minutes to complete
Answer the following questions on a scale of 0-3:

“0” (least/never/no/zero symptoms)
“1” (minor/mild/rarely/not really/monthly),
“2” (moderate/occasionally/somewhat/weekly),
“3” (most/severe/frequently/absolutely/daily).
Take your time and be honest with the answers.
Accurate answers will allow your coach to understand your health priorities.

Personal Details
Name*
First Last
Email*
Your Coach's Name*
Today's Date*
DD slash MM slash YYYY
Section 1
I crave sweets and/or carbohydrates*
I crave sweets after meals*
I am frequently thirsty*
I feel tired after meals*
I get blurred vision*
Section 1 Total Score
Section 2
I get shaky and irritable between meals*
Eating energizes me and/or relieves fatigue*
I often wake up during the night*
I get fatigue, fuzzy thinking, headaches between meals*
I get anxiety and palpitations*
Section 2 Total Score
Section 3
I have bleeding gums or nosebleeds, or get easily bruised*
I get muscle fatigue or excessive soreness after exercise*
I get tingling in hands or feet, and/or cracking in the corners of the mouth*
I have restless legs, and/or muscle cramping/twitching*
I have dry/scaly skin and/or bumps on the back of my arms*
Section 3 Total Score
Section 4
I feel tired, fatigued, or weak*
I experience shortness of breath*
I get cold hands and feet, or “poor circulation”*
I experience a rapid, or irregular heart beat*
I get dizziness or lightheadedness*
Section 4 Total Score
Section 5
I get anxious, moody, and irritable*
I get negative and combative*
I experience fatigue, weakness and daydreaming*
I experience confusion and impaired judgement*
Fasting is difficult and uncomfortable*
Section 5 Total Score
Section 6
I have gut issues such as diarrhoea, constipation, heart burn*
I don’t react well to exercise, or get weakness or cramping*
I experience mood swings, migraines, balance/coordination problems*
I experience visual or hearing disturbances*
I have generalized fatigue, or fatigue easily*
Section 6 Total Score
Section 7
I get bloated shortly after meals*
I experience heartburn, or use antacids*
I excessively belch or burp*
I am sensitive to a number of foods*
I get indigestion or nausea after eating*
Section 7 Total Score
Section 8
I have excessive and/or foul-smelling gas*
I get lower abdominal bloating relieved by gas*
I get constipation, diarrhoea, or both*
I have a history of antibiotic use*
I have a history of laxative use*
Section 8 Total Score
Section 9
I get nausea or diarrhoea from high-fat foods*
I get “greasy” stool that tends to float*
I am sensitive to caffeine, alcohol, and or other synthetic chemicals*
I get general itchiness, or itchy palms*
I have had my gall bladder removed: yes (=3), no (=0)*
Section 9 Total Score
Section 10
I am sensitive to the smell of chemicals and/or perfumes*
I live or work near heavy traffic, factories, electricity towers or cell phone towers*
I experience chronic airway issues, nasal congestion, mucous production, or nose/throat issues*
I experience chronic headaches, muscle or joint stiffness/pain, or skin issues*
I am exposed to synthetic fabrics, tap water, cosmetics, cleaning products and processed foods*
Section 10 Total Score
Section 11
I get less than 6 hours of sleep at night, have disrupted sleep, or sleep at abnormal hours*
I routinely consume canola, corn, or safflower oil*
I experience chronic psychological stress*
I am physically inactive*
I have been diagnosed with elevated iron (3=yes, 0=no)*
Section 11 Total Score
Section 12
I experience joint pain and swelling*
I get skin problems and rashes*
I have had a sudden onset of symptoms ,which have progressively worsened over time*
I get swollen glands and/or sore, aching muscles*
I have a family history of autoimmune disease (yes=3, no=0)*
Section 12 Total Score
Section 13
I have chronic pain and or lasting fatigue*
I don’t wake up refreshed*
I get extreme fatigue after exertion*
I have persistent mental/emotional challenges*
I frequently get headaches and/or pain*
Section 13 Total Score
Section 14
I get constipation, diarrhoea, gas or IBS*
I have difficulty falling asleep or staying asleep*
I get skin irritations, rashes, hives, or eczema*
I am often hungry or unsatisfied after meals*
I have a history of allergies and/or asthma*
Section 14 Total Score
Section 15
I get itchy or flaky skin*
I experience visual disturbances*
I get headaches, “spaciness”, or neurological deficits*
I have a history of antibiotic use*
I have a history of athlete’s foot, jock itch, toe nail fungus, or yeast infections*
Section 15 Total Score
Section 16
I find it difficult to get going in the morning*
I have difficulty falling asleep, I’m a “night person”*
I often feel “tired and wired”*
I perspire easily, even with minimal activity*
I have high blood pressure*
Section 16 Total Score
Section 17
I crave salt or liberally salt food*
I feel lightheaded when standing up quickly*
I have difficulty staying asleep*
I have low blood pressure*
I get fatigue and/or depression*
Section 17 Total Score
Section 18
I tend to be cold, especially my hands and feet*
I have difficulty losing weight*
I have low energy, or I’m tired all the time*
I get brain fog, mental sluggishness*
I have dry skin, brittle nails, hair loss*
Section 18 Total Score
Section 19 (Males Only)
I have decreased libido
I have a decrease in morning erections or strength in erections
I have decreased enjoyment in life
I have decreased strength and/or endurance
I have difficulty building or maintain muscle
Section 19 Total Score
Section 20 (Females-Menstruating Only)
I have acne and/or unwanted facial hair growth
I have abnormal menstruation (heavy, extended, shortened, scanty)
I get pain, cramping and/or breast tenderness during menses
I have significant mood changes during menses
I am currently taking, or have a history of taking, birth control
Section 20 Total Score
Section 21 (Females – Menopausal Only)
I experience hot flushes
I have acne, and/or unwanted facial hair growth
I get mood swings, depression, night sweats
I have vaginal thinning, dryness, or itchiness
I have a low libido
Section 21 Total Score
Section 22
I have a lack of motivation*
I have feelings of worthlessness, or destructive thoughts*
I am quick to anger or get frustrated*
I am inattentive, and have disorganized thinking*
I have decreased pleasure in life*
Section 22 Total Score
Section 23
I have a loss of enjoyment in my favourite activities, or relationships*
I get feelings of depression and sadness*
I have gut distress and/or decreased pain tolerance*
I get feelings of overwhelm, or obsessive thoughts*
I lack deep, restful sleep*
Section 23 Total Score
Section 24
I get feelings of anxiety, panic, or inner tension*
I experience mental or physical restlessness*
I get easily worried*
I feel easily overwhelmed and overworked*
I have insomnia or difficulty sleeping*
Section 24 Total Score
Section 25
I experience rapid and shallow breathing*
I have a rapid heart rate*
I get fatigued*
I have headaches*
I have a lack of appetite*
Section 25 Total Score
Section 26
I get lightheaded*
I experience muscle twitching, spasms or cramps*
I get numbness or tingling in my face, hands or feet*
I get tremors, especially in my hands*
I have a slow breathing rate*
Section 26 Total Score
Section 27
I don’t drink water between meals*
I frequently urinate*
I have loose or watery stools*
My sweat is excessively salty*
I am frequently thirsty*
Section 27 Total Score
Section 28
I feel as if nobody understands me*
It is difficult for me to make friends*
People are around me, but not with me*
My social relationships are superficial*
No one really knows me well*
Section 28 Total Score
Section 29
I don’t feel in control of my life*
My life is not rewarding, I am not optimistic about the future*
I am not satisfied with my life*
I don’t feel healthy, attractive, or pleased with who I am*
I find it hard to see the beauty and joy in things, or laugh*
Section 29 Total Score
Section 30
I can’t easily, succinctly articulate my purpose in life*
I haven’t discovered who I really am*
I don’t feel involved in, or feel fulfilled by many of the things I do each day*
My life is not centered around a set of core beliefs that give meaning to my life*
It is more important that people are impressed by what I do rather than I enjoy it*
Section 30 Total Score
Do you have any information that you'd like to add about your answers in this assessment?

Cell Blueprint Assessment

Personal Details

Section 1

Section 2

Section 3

Section 4

Section 5

Section 6

Section 7

Section 8

Section 9

Section 10

Section 11

Section 12

Section 13

Section 14

Section 15

Section 16

Section 17

Section 18

Section 19 (Males Only)

Section 20 (Females-Menstruating Only)

Section 21 (Females – Menopausal Only)

Section 22

Section 23

Section 24

Section 25

Section 26

Section 27

Section 28

Section 29

Section 30

Company