This is a sample of one of the body systems assessment I use with clients.
If you have the symptoms in the last 6 months –frequent (multiple times weekly), moderate, or intermittent, mark that symptom.
For symptoms farther back than 6 months, you can include it on your intake history.
Sections will show what body systems may be imbalanced.
Note that some symptoms are listed in multiple sections. This is because an imbalance one system can have different root causes.
Clients will have the body system description of the sections. There are 14 sections in total.
Please Contact me or fill out the Client Assessment Application if you would like to have the full assessment.
0-5: System likely does not require support at this time
5-15: System may benefit from General Support
15-25: System may benefit from Specific Support
25-35: Strong indication of Specific Support
Section 1:
Acid indigestion, heartburn, or acid reflux -2
Anxiety, nervousness, fear -1
Asthma -1
Brittle nails or other nail problems -1
Chronic fatigue or lack of stamina -1
Chronic post nasal drip -1
Cold sores or mouth ulcers (canker sores) -1
COPD, emphysema, chronic lung disease -1
Cravings for sweets or sugary foods -1
Diabetes, blood sugar over 90 mg/dL -1
Excessive intestinal gas, flatulence -2
Food allergies -2
Food sits heavy on stomach after meals -2
Frequent belching or bloating -1
Frequent mental and emotional stress -1
Frequent thirst, dry mouth -1
General feeling of weakness, lingering chronic illness -2
Groggy or tired feeling in the morning -1
Hair loss or thinning -1
Hay fever, respiratory allergies, allergic rhinitis -1
Headache, feeling of pressure or tension -1
Less than 1 bowel elimination per day -1
Loss of appetite; poor appetite -2
Overweight, difficulty losing weight -2
Pale complexion or anemia -1
Respiratory infections (frequent) -1
Underweight; unable to gain weight -2
TOTAL for Section 1: _____________
Section 7:
Absent-mindedness or memory loss -2
Anger, irritability, easily upset -1
Anxiety, nervousness, or excessive fear -2
Asthma -1
Chronic fatigue or lack of stamina -1
Chronic tension or muscle cramps -1
Depression, feeling down or discouraged -1
Difficulty getting to sleep -2
Dizzy or light headed -1
Feeling “burned out” or exhausted -1
Frequent mental and emotional stress -2
Frequent mood swings, moody -1
Frequent neck and shoulder pain -1
Grief, sadness, self-pity -1
Groggy or tired feelings in the morning -1
Headache, feeling of pain or tension -1
Headaches, migraines with pounding or throbbing pain -1
High blood pressure, hypertension -1
Infertility -1
Irregular heart rate (arrhythmia)- 1
Irregular menstrual cycle (female) -1
Leg cramps, restless leg syndrome -1
Loss of appetite or poor appetite -1
Loss of self-confidence and motivation -1
Loss of sexual desire -1
Menstrual cramps (female) -1
Muddled thinking or confusion -1
Overweight or difficulty losing weight -1
Rapid heart rate (tachycardia) -1
Restless disturbed sleep, frequent waking -1
Underweight or unable to gain weight -1
TOTAL for Section 7: _________
Section 9:
Asthma -1
Cholesterol over 275 mg/dL -1
Cholesterol under 175 mg/dL -1
Chronic fatigue or lack of stamina -1
Chronic or frequent dry cough -1
Chronic post nasal drip -1
Cold sores or mouth ulcers (canker sores) -1
COPD, emphysema, chronic lung disease -2
Coughing yellow or green mucous -1
Dark circles under eyes -1
Difficulty breathing, shortness of breath -1
Eczema, psoriasis or severe acne -1
Excessive intestinal gas, flatulence -1
Feeling “burned out” or exhausted -1
Food allergies -2
Frequent belching or bloating -1
General feeling of weakness, lingering chronic illness -2
Grief, sadness, self-pity -1
Hay fever, respiratory allergies, allergic rhinitis -1
Inflammatory bowel disorders, colitis, Crohn’s disease -1
Itchy nose, ears, or skin –1
Less than 1 bowel elimination per day -1
Pale complexion or anemia -1
Respiratory infections (frequent) -2
Sinusitis or chronic sinus congestion -1
Skin ulcerations or wounds not healing -1
Swollen lymph nodes -2
Urinary tract infections (frequent) -1
Vaginal discharge, infection (female) -2
TOTAL for Section 9: _________
Drémari Holistic Wellness 