1. Are you lacking energy and feeling tired often?
   Yes    No
2. Are you pale?
   Yes    No
3. Do you have dark circles under your eyes?
   Yes    No
4. Do you have a decreased ability to exercise?
   Yes    No
5. Do you have ridged fingernails and/or brittle hair?
   Yes    No
6. Do you find yourself becoming more easily short-of-breath with exertion?
   Yes    No
7. Does it feel like your pulse is pounding or your heart racing?
   Yes    No
8. Do you have a hard time concentrating?
   Yes    No
9. Do you suffer from dizziness or buzzing in your ears?
   Yes    No
10. Do you have increased infections?
    Yes    No
11. Is your tongue sore?
    Yes    No
12. Do you crave starch, ice, clay or dirt?
    Yes    No
13. Has your appetite decreased?
    Yes    No
14. Do you suffer from dull headaches or restless legs?
    Yes    No
15. Do you eat less than 4 cups of vegetables per day?
    Yes    No
16. Are you a vegetarian?
    Yes    No
17. Have you tried many different weight loss diets, or do you diet often?
    Yes    No

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