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Step 1 of 4 – Lifestyle Questions

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Please answer the following 10 questions with what best describes who you are and what you experience. Trust your instincts and mark the answer that immediately comes to mind when reading the question.
Which best describes your brain “personality”?
- I am a worrier
- I am a positive person
- I am driven
- I am laid back
- I am anxious
- I am calm
Which best describes your brain function?
- My brain is constantly busy all day long — I have continuous thoughts
- My brain is busy when I need it to be, but I easily turn thoughts off at the end of a day
- My brain is never constantly busy
Which best describes your current body type?
- I have ideal body composition
- I have excess weight all over (midsection as well as extremities)
- I have excess midsection body weight but normal extremities
- I carry excess weight in my buttocks and thighs
- I am underweight for my height
Which best describes how you generally feel after eating?
- Tired
- Bloated
- Relaxed
- Nourished
- Stuffed
- Achy
- Allergic
- Content
Which best describes your current eating pattern? Assume that the standard is eating breakfast, lunch and dinner at regular intervals.
- I frequently delay or do not eat breakfast
- I frequently skip at least one meal a day
- I frequently binge eat — overeating too much food at one time
- I frequently overeat — I feel too full after eating
- None of the Above
Which best describes your cravings?
- I frequently crave sugary foods or drinks and give in to those cravings
- I frequently crave salty/savory foods and give in to those cravings
- I frequently crave both sugary and salty/savory foods and give in to those cravings
- I frequently crave sugary foods or drinks but do not give in to those cravings
- I frequently crave salty/savory foods but do not give in to those cravings
- I frequently crave both sugary and salty/savory foods but do not give in to those cravings
- I do not have frequent cravings for either sugary or salty/savory foods
Which best describes your bowel movements?
- Well-formed, normal consistency
- Loose
- Hard
Which best describes your sleep pattern?
- I usually get at least 7 to 8 hours of uninterrupted sleep a night
- My sleep is interrupted but in total I sleep at least 7 hours a night
- My sleep is interrupted and I get less than a total of 7 hours a night
- I am up most of the night
Which best describes your sleep pattern without the use of sleeping pills or over-the-counter sleeping aids?
- I do not have any problem falling asleep or staying asleep
- I do not have any problem falling asleep, but I wake up in the night and cannot fall back to sleep easily
- It takes me at least an hour to fall asleep, but once asleep I sleep the whole night
- It takes me at least an hour to fall asleep, and I wake up in the night and cannot fall back to sleep easily
- Does not apply since I take sleeping pills
Which best describes how you feel immediately upon completion of your exercise
- My brain is calm and my body is relaxed
- I have a sense of well-being, and I don’t feel tired or wired
- I have frenetic energy
- I exercise to a point that makes me physically or mentally tired/wired
- I feel like I overdid it

Please indicate whether you have been diagnosed with any of the following diseases.*
- Advanced Degenerative Nervous System Disorder (such as Parkinson’s, Advanced Multiple Sclerosis, Lewy Body Dementia)
- Alzheimer’s dementia
- Chronic Kidney Disease – Stage 3 or greater
- Congestive Heart Failure
- Liver Failure
- Metastatic Cancer
- Stroke that caused lasting impairment to verbal skills or cognitive function
- Transplanted Organ on immunosuppressive drugs – heart, lungs, liver or kidneys
- None of the Above
Have you been diagnosed with Type II Diabetes?*
- Yes
- No
Together with Type II Diabetes, have you been diagnosed with any of the following:*
- Heart attack causing significant damage to the heart
- Congestive heart disease
- Kidney failure
- Ongoing cancer
- Stroke with lasting impairment in cognitive or verbal skills
- None of the above
Have you been diagnosed with Type I Diabetes?*
- Yes
- No
Together with Type I Diabetes, have you been diagnosed with any of the following:*
- Major organ failure such as kidney or liver failure
- Severe and frequent hypoglycemic episodes
- Brittle diabetes – wildly fluctuating blood sugar levels
- Heart attack causing significant damage to the heart
- Stroke with lasting impairment in cognitive or verbal skills
- Congestive heart disease
- Ongoing cancer
- None of the above
Have you been diagnosed with Chronic Severe Lung Disease – COPD or Emphysema*
- Yes
- No
Check any that describe your situation:*
- I am on oxygen therapy
- My activity is severely restricted due to my lung disease
- I am always short of breath
- I am dependent on steroids
- I am dependent on bronchodilators
- None of the above
Have you been diagnosed with an Autoimmune Disease?*
- Yes
- No
Check any that describe your situation:*
- I am on immunosuppresant drugs
- I have kidney or liver damage
- None of the Above
Have you been diagnosed with Heart Arrhythmia including Atrial Fibrillation?*
- Yes
- No
Is your Heart Arrhythmia well controlled on medication?*
- Yes
- No
Together with Heart Arrhythmia, have you been diagnosed with any of the following:*
- Chronic Lung Disease
- Congestive Heart Failure
- Heart Attack
- None of the Above
Do you have ongoing Depression (not due to a current atypical circumstance) requiring treatment such as seeing a psychologist/therapist and/or taking medication(s)?*
- Yes
- No
Describe your situation regarding your depression:*
- I currently have or recently have had suicidal or homicidal thoughts
- I am not stable on my medication
- None of the above

Please mark any of the following conditions for which you have received a diagnosis. Please make sure to include only those that are severe. For instance, occasional joint pain does not mean you have Osteoarthritis. Getting hypoglycemic feelings if you have delayed eating, does not constitute a Hypoglycemia condition. Being a worry wart does not mean you should mark Anxiety Disorder. Your thoughtful response will lead to a more accurate assessment of your metabolic profile.
Do you have any of the following medical conditions?*
- Abnormal Blood Sugar Levels – HbAIC between 5.7% and 6.3% diagnosed after being on an eating plan that eliminates or drastically reduces complex carbohydrates
- Anxiety Disorder
- Asthma
- Chronic Fatigue Syndrome
- Chronic Hives/Severe Eczema/Psoriasis
- Fibromyalgia
- Hypervigilance or chronically being aware of your surroundings and circumstances to prepare yourself for perceived threats
- Irritable Bowel Syndrome
- None of the Above
Do you have any of the following medical conditions? (continued)*
- Abnormal Blood Sugar Levels – HbAIC between 5.7% and 6.3% diagnosed while eating complex carbohydrates
- Abnormal Cholesterol Levels (triglycerides greater than 200 mg/dl with HDL less than 35 mg/dl for men and less than 40 mg/dl for women regardless of total cholesterol levels)
- Hypertension requiring medication with increased distributed fat weight in torso and extremities – not just midsection
- Metabolic Syndrome – sometimes called “pre-diabetes”
- Polycystic Ovarian Disease (PCOS) aka Stein-Leventhal Syndrome
- None of the Above
Do you have any of the following medical conditions? (continued)*
- Chronic Constipation
- Coronary Artery Disease without heart attack or congestive heart failure
- Fat Weight Gain that does not respond to diet and/or exercise
- Insomnia (chronic sleep disorder)
- Migraine Headaches (severe) that occur more than 4 times a month
- Osteoarthritis (not due to sports injury)
- Osteoporosis
- Stroke that caused NO lasting impairment to verbal skills or cognitive function
- None of the Above
Do you have any chronic medical condition about which we have not asked?*
- Yes
- No
Please explain including how long you have had this condition:*
Your results may be delayed while we look into your condition.

CONGRATULATIONS!
YOU HAVE COMPLETED THE METABOLIC QUIZ

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Schwarzbein Principle Programs, Inc.

350 S. Hope Ave,

Suite A102,

Santa Barbara, CA,

93105

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Step 1 of 4 – Lifestyle Questions

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CONGRATULATIONS!
YOU HAVE COMPLETED THE METABOLIC QUIZ