1. How often do you experience anxiety?

2. How often do you experience stress?

3. Do you have trouble sleeping?

4. Do you have restless legs?

5. Are your hands or feet cold due to poor circulation?

6. Do you have twitching around your eyes or facial muscles?

7. How often do you get muscle cramps or spasms?

8. How often do you get headaches or migraines?

9. How often are you fatigued, lethargic, or low on energy?

1. How often do you eat leafy vegetables?

2. How often do you eat beans?

3. How often do you eat nuts and seeds?

4. Do you eat foods with high sugar, fats, or salt?

5. Do you drink more than 7 alcoholic beverages per week?

6. Do you drink more than 3 cups of coffee or tea per day?

7. Are you taking any kind of diuretic such as Lasix, Aldactone, Microzide?

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