Organ Questionnaire--Liver Self-Assessment

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This form enables you to assess the health of your liver. There are several items in one question and then an opportunity to explain.

Please respond whether you have any of the following symptoms:

Email *

Do you have JAUNDICE? That is, yellowing of the skin and whites of the eyes? *

Yes

Color of Stool *

Pale or light colored

Yellow Diarrhea

None of these

Required

Is your Urine darkly colored? *

Yes

Do you experience pain or pressure in any of the following ways?

Pain or pressure at the bottom of your right rib cage?

If you lie on your left side, does it feel like it is heavy or dragging down from the right rib cage?

To you have pain on the inner side of either of your scapulae (shoulder blade)? *

Yes

Are you generally chillier than most people? *

Yes

Please mark an X by any of the following skin symptoms that you experience. *

Liver spots (yes, they are real)

Eczema

Psoriasis

Acne Rosacea

Cellulite

Lipomas (fatty lumps under the skin)

Easy facial flushing

Excessive blood vessels in your face or on your nose.

Required

Please add any information you wish to the above question.

Do you have any of the following digestive issues? Please check all that apply. *

Yellow coating on the tongue

Bad breath

Slow to develop and resolve migraine headaches

Constipation

Poor appetite in the mornings

Craving sweets

Worse from alcohol

Made worse from eating fat

Diarrhea from rich foods

Required

Please add any additional information you wish to the above question

Do you have circulatory symptoms, including hemorrhoids and varicose veins? *

Yes

Does your body shape consist of a roll of fat around the upper abdomen? *

Yes

Do you have swelling (bags) under the eyes just above the boney orbit of your eye socket that are darkly colored? *

Yes

Do you have any sensory symptoms including any of the following? *

Tinnitus

Floaters in the field of vision

Other:

Required

Please add any additional information about the above 4 questions.

Do you have any of the following Mental Health symptoms? *

Hyper willful (sometimes called controlling)

Hypo willful (sometimes called indecisive or lack of will power)

Problems with conflict and aggression--either causing it or avoiding it

Anger or irritability

Depression

Poor concentration

Brain fog, especially in the morning

Other:

Required

Please add any additional information about the above question.

Do you wake up feeling unrefreshed and unrested? *

Yes

Please add any additional information about the above question.

Do you wake up between 2:30 -4:00 a.m.? *

Yes

If you answered yes to waking between 2:30 - 4:00 a.m., how long do you stay awake before you are able to all back to sleep?

A copy of your responses will be emailed to the address you provided.

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