Syndrome X Questionnaire Part 1: Your Family and Personal Medical History 1. My Grandparents have or had: (1 point for each Grandparent): adult-onset diabetes. 01234 grandparent(s) high blood pressure. 01234 grandparent(s) heart disease or atherosclerosis. 01234 grandparent(s) difficulty controlling weight. 01234 grandparent(s) high fat levels in the blood 01234 grandparent(s) 2. My Parents have or had (2 points for each Parent): adult-onset diabetes. 012 parent(s) high blood pressure. 012 parent(s) heart disease or atherosclerosis. 012 parent(s) difficulty controlling weight. 012 parent(s) high fat levels in the blood 012 parent(s) 3. I have adult-onset diabetes (15 points) high blood pressure (4 points) heart disease or atherosclerosis (8 points) difficulty controlling weight (4 points) high fat levels in the blood (6 points) 4. I am not over weight, but I do struggle to control my weight (1 point) less than 20 pounds over weight (2 points) 20 – 50 pounds over weight (3 points) 51 – 100 pounds over weigh (4 points) more than 100 pounds over weight (6 points) 5. I am between 35 and 49 years of age (1 point) between 50 and 64 years of age (2 points) over 65 years of age (3 points) Total for Part 1: Part 2: Your Nutritional and Life Style Profile Point Value Check if applicable 6. I eat sweets (such as candy, ice cream, pastries or doughnuts) 4 or more times a week. 4 7. I eat “fat-free” foods (such as fat-free muffins, fruit yogurt, cookies, breakfast bars more than 4 times a week. 2 8. I eat potato chips, pretzels, breakfast bars, granola, or ready-to-eat breakfast cereals more than 3 times a week. 2 9. I eat meals that emphasize pasta, rice, corn or potatoes more than 3 times a week. 2 10. I eat burgers, hot dogs, fatty luncheon meats (bologna, ham, salami), bacon, sausage, french fries or fried chicken more than 3 times a week. 2 11. I eat convenience food (pizza, fast food style Mexican, sandwiches, or snack food) more than 3 times a week. 2 12. I drink regular (non-diet) soft drinks or sweetened ice tea more than 3 times a week. 2 13. I drink more than eight ounces of undiluted fruit juice per day. 1 14. I snack between meals. 1 15. I drink more than 2 cups of coffee or tea with sugar or sweetener daily. 4 16. I often chew gum, eat mints or hard candy (sweetened or diet). 2 17. I often eat when I am not hungry. 2 18. I eat food high in saturated fats almost every day. 2 19. I often snack at night. 2 20. I avoid structured exercise. 2 21. I avoid any exercise like walking, taking stairs, housework, gardening, playing with children or a pet. 4 22. I have been a “couch potato” for many years. 3 Total for Part 2 (possible total: 39) Part 3: Stress Levels 23. I am under a great deal of stress: at my job but not at home (2 points). at home but not work (3 points). at home and at work (6 points). 24. I smoke: less than one pack of cigarettes a day (2 points). between one and two packs of cigarettes a day (6 points). more than two packs of cigarettes a day (8 points). cigars or a pipe (3 points). 25. I drink beer or wine: on occasion, but then fairly large amounts (2 points). two or three times a week more than 2 glasses (1 points). once a day, one or two glasses (0 points). twice or more a day (5 points). 26. I drink mixed drinks: on occasions, but then fairly large amounts (2 points). two or three times a week more than 2 glasses (1 point). once a day, one or two glasses (2 points). twice or more a day (6 points). 27. I take birth control pills or female hormone replacement medication (2 points). Total for Part 3 Part 4: Symptom Quiz Condition Point Value Check if applicable 28. I often feel tired, particularly after eating lunch or dinner. 1 29. I have difficulty concentrating. 1 30. My thinking is frequently fuzzy or spacey. 1 31. I often get irritable or angry. 1 32. I experience frequent cravings for sugar or other carbohydrates such as pasta, bread or baked goods. 4 33. I have a tendency to binge on sweets or other carbohydrates. 2 34. I feel shaky if I don’t eat on time or if I don’t get snacks. 4 35. I have a tendency to gain weight easily and have difficulty losing it. 3 36. I have a “pot belly” around my waist (males). 6 37. I carry fat more in my abdominal region or upper body instead of on my hips and thighs (female). 6 38. I feel the need to urinate frequently. 5 39. I often have unexplained thirst. 5 Total for Part 4 (possible total 39) Total for part 1 Total for part 2 Total for part 3 Total for part 4 GRAND TOTAL (possible total 195) If your score is between 0 and 15 congratulations – there is minimal risk of Syndrome X or insulin resistance. Your lifestyle and diet reflect a healthy resource that you should maintain. Take this quiz once a year to determine if you are still in this health range. If your score is between 16 and 25 you appear to be at the first stages of insulin resistance. By making a few fundamental changes to diet and lifestyle now, you can avoid the adverse consequences of Syndrome X. If your score is between 26 and 50 you probably have insulin resistance and are heading into Syndrome X. This is the time to take action before this issue becomes a driving force in your life. You need a program including proper diet, supplements and exercise. If your score is above 50 points you definitely have Syndrome X and insulin resistance as a major issue in your health profile. It is essential that you take strong and immediate action to reverse this situation. You need a program including proper diet, supplements and exercise. Understanding your score: Insulin resistance is the result of your body’s inability to process large amounts of dietary carbohydrates such as sugar, bread and pasta. Some of the initial signs include fuzzy thinking and having a tired feeling after meals or at mid afternoon (2 – 6 pm). By definition, Syndrome X consists of a combination of insulin resistance and one or more of the following health issues: upper-body obesity, high blood fats (cholesterol or triglycerides) or high blood pressure. Syndrome X has been shown to greatly increase the risk of heart disease, diabetes, cancer, Alzheimer’s disease and a several other age-related mental and physical issues. It ages the body prematurely.