Total: # Yes_______   #No______

These educational measures will give you concrete numbers that you can look back on to assess how effective this program, or any other program, supplement, or medication is. 

Please complete before the start of the Warm Bone System Program. We are looking at patterns of how well your body is running as a whole system, not one time events. So if you are bloated after every meal, then note that. However, if you get bloated after a night of pizza, beer, and ice cream, then don’t record that as most people with even the healthiest of digestions would not do well with that dinner! 

(1) Appetite: #Yes_______   #No______

1. Do you get hungry for, and eat, 3 meals a day?
2. Are you omnivorous, meaning do you eat from all food groups?
3. Does most of your diet consist of real, whole foods (unprocessed and unpackaged).

(2) Digestion: #Yes_______   #No______

1. Generally speaking, when food goes in, does it feel like it sits well?
2. In the past two weeks have you been free of gassiness to the point of discomfort, or gas with a very strong odor?
3. In the past two weeks have you been bloat-free?
4. In the past two weeks have you been free of acid reflux or a feeling of burning in your stomach?

(3) Bowels: #Yes_______   #No______

1. Do you usually have 1-2 bowel movements a day? (if more than 2, say “no.”) 
2. Are your bowels most often easy to pass, with no strong smell, and formed. They are not too hard, nor too soft, and there is no urgency? (like you could have an accident)

(4) Sleep: #Yes_______   #No______

1. Are you generally able to fall asleep easily-within 20 minutes of laying down – without sleep medication or supplement aid?
2. Do you tend to stay asleep throughout the night? Or if you wake for some reason are you able to fall back asleep within 20 minutes?
3. Do you have vivid dreams less than once a month?
4. Do you get night sweats less than once every two weeks?

(5) Energy: #Yes_______   #No______

1. Do you wake most of the time feeling rested and ready to get out of bed?
2. Is your energy consistent between 10-11am and/or 3-5pm?
3. Do you have enough energy throughout the day to do what you need to do without relying on caffeine?  

(6) Thirst: #Yes_______   #No______

(When entering up top, record the “yeses” as “nos.” This will keep the scoring consistent)

1. Are you either always thirsty or never thirsty?
2. When you drink, is it difficult to be satisfied by water? Does it never seem to quench your thirst?
3. When you drink water, does it sit in your stomach or slosh around?
4. Do you crave drinking either very hot or very cold water?

(7) Sweat: #Yes_______   #No______

1. Do you feel like you sweat normally? I.e. is your sweat proportional to your exertion? (some people never sweat, others sweat for what seems like no reason)
2. In the past two weeks have you been free of night sweats or spontaneous sweat during the day?
3. In the past two months, has your sweat had the absence of a strong hormonal smell?

(8) Urination #Yes_______   #No______

1. Is your urine pale yellow (except for the first morning urination)?
2. Does your urination seem proportional to the amount of liquids you drink?
3. Is your urine free of cloudiness, foam, odd odor, or anything else unusual?
4. Do you experience UTIs less than 2x a year?

(9) Temperature #Yes_______   #No______

1. Do you tend to run neither hotter than other people nor colder than other people?
2. Are you able to adjust to and be comfortable in a wide range of temperatures and humidities?
3. Will your hands and feet rarely get cold easily?
4. Do you rarely have a problem falling asleep because you are cold?
5. Do you rarely get so hot that you feel like you are suffocating, or that you need to keep the house below 70 degrees in order to be comfortable?

(10) Temperament #Yes_______   #No______

1. Everybody has every emotion, it's what makes us human. But do you feel free from any emotion that is like a cloud following you around, that could be affecting your health?
2. Do you experience panic attacks less than once a year?
3. Do you rarely have cycles of depression where you lose motivation, don't feel like seeing people, and either cry or become angry too easily?
4. Do you rarely lash out in anger, either uncontrollably or where it takes you by surprise?

(Bonus for Women) Menses: #Yes_______   #No______

1. Is/was your menstrual cycle generally between 26 and 32 days?
2. Does/did your menses last 3-5 days and begin and end cleanly?
3. Do/did you have the absence of any of the following: clots, mucous or blood that is not red?
4. Thinking back over the last 3 menstrual cycles, did you have no significant PMS in the week before menses-either physically or emotionally?

For educational purposes only. Using this form does not constitute medical advice, nor does it establish any kind of patient-practitioner relationship whatsoever. No part of this document may be redistributed without the written permission of MyoSinew Therapy LLC.