Structural Client
Diagnostic Framework
Reading the Structure Behind the Symptom
Every symptom a client presents with is a downstream expression of a structural pattern that began upstream — often years earlier, often invisibly. This diagnostic framework reads in both directions at once: toward the biological mechanics of the body and toward the structural architecture of the life. Neither reading is complete without the other. They are the same cascade, read at different scales.
The diaphragm is the body's central structural crossing point. The life patterns a client carries are encoded in the same body that stopped breathing freely decades ago. These questions map both. They are designed to reveal where the structure locked, not merely what the client feels about it.
Presenting Conditions & History
A structural diagnosis begins not with the chief complaint but with the pattern behind the complaints. The goal here is not a symptom list. It is the architecture of the timeline.
- What brings you here, and when did you first notice something was structurally off — not wrong, but patterned?Not the diagnosis. The first moment the body gave you information you didn't know how to use.
- If you map your health history chronologically, what is the first event you would mark?Not necessarily a diagnosis — an event, a period, a transition.Cascade read: establishing timeline origin relative to structural or life events
- What conditions, diagnoses, or symptoms are you currently managing?Of those, which have you accepted as permanent versus which still feel like there is something to understand?
- How many practitioners are currently involved in your care, and what does each address?The specialist map reveals what the body is expressing across systems simultaneously.
- What interventions have produced partial improvement? What specifically improved, and what did not shift?Cascade read: partial response indicates depth — structural vs. recruited-system level
- What have you been told by practitioners that has not resonated with your own experience of your body?
- List all current medications, including dose and how long you have been taking them.
- List all supplements, including dose, frequency, and what you are taking them for.
- Are you taking hormonal contraception, HRT, or any hormone-modifying medication?Hormonal architecture: will obscure natural hormone patterns — note for downstream interpretation
- Are you currently taking corticosteroids, SSRIs, PPIs, thyroid medication, or metformin?Each has specific nutrient depletion and cascade interaction profiles.
- What stimulants do you use regularly — caffeine, pre-workout, Adderall, modafinil? Amount, timing, and what they are compensating for.Cascade read: stimulant dependency maps where adrenal / HPA recruitment is most active
- What are the significant health conditions in your immediate family — parents, grandparents, siblings?
- Are there conditions that appear in multiple generations? Name the pattern, not just the diagnosis.Inherited charge ceiling: multi-generational patterns indicate structural transmission
- Were there significant health, survival, or trauma events in your family system that preceded your birth?
The Structural Axis & Diaphragm Assessment
The spine is the body's first structural event. The diaphragm is its central crossing point. Every chronic condition in this framework traces back to what happens at this junction.
The diaphragm coordinates breathing, circulation, digestion, and autonomic regulation simultaneously. A locked diaphragm is sufficient to initiate the cascade behind every major category of chronic disease. These questions are not breathing exercises — they are structural diagnostics.
- Describe your resting posture — not the posture you try to hold, the one your body defaults to when you stop thinking about it.Polarity read: anterior collapse (flow surface closing) vs. posterior bracing (containment dominance)
- Do you have any diagnosed spinal conditions — disc herniation, scoliosis, stenosis, kyphosis, spondylosis?If diagnosed, at which levels? How long have you been aware of it? Was there a precipitating event?
- Do you have a history of significant physical impact — accidents, falls, sports injuries, surgical procedures under general anaesthesia?Structural trauma: cascade often initiates at the moment of physical impact or perioperative period
- Where do you hold chronic muscular tension? Be specific — not "my shoulders," but which part, what position, constant or variable with stress?
- Do you have asymmetry in your body — one hip higher, one shoulder forward, your head carrying off-centre?Bilateral polarity: axis shift creating two asymmetrical polarity zones that cannot coordinate as designed
- Do you have chronic pain? Describe location relative to spinal regions — cervical, thoracic, lumbar, sacral — and whether it radiates.
- When you breathe at rest, where does the breath primarily move — your belly, your chest, or your upper chest and neck?If unsure, place one hand on belly and one on chest — notice which hand rises first on inhale.Cascade Stage 5: chest breathing indicates diaphragm is offline — accessory muscles now primary breathing mechanism
- Do you frequently sigh, yawn, or feel like you cannot get a fully satisfying breath?Pump failure signature: the body attempting to recruit full diaphragm excursion and failing
- Do you breath-hold — during concentration, stress, reading, or physical tasks?
- Do you experience tightness, pressure, or restriction across the lower ribcage or solar plexus, particularly under stress?
- Do you have a history of asthma, chronic hyperventilation, or respiratory conditions?Cascade Stage 2 / Respiratory depth: condition originated or amplified at the respiratory level of the cascade
- Is your breathing rate typically fast, slow, or irregular? Has anyone ever commented on your breathing pattern?
- Do you have any pelvic floor symptoms — urinary urgency or leakage, pelvic pain, pressure, or awareness of pelvic tension?Container Stage 2: pelvic floor has lost its diaphragmatic partner — hypertonic or hypotonic response
- Is your abdomen typically soft and moveable, or does it feel rigid or gripped independent of fat distribution?
- Do you experience abdominal bloating that changes throughout the day — better in the morning, worse by evening?
- Have you had abdominal surgery, C-section, or significant abdominal trauma? Are there visible or palpable surgical scars?Fascial continuity: scar tissue creates regional containment lock propagating through the web
Cascade Depth Assessment
The cascade begins as a mechanical event and becomes hormonal through a predictable recruitment sequence. These questions map how far it has penetrated — which determines the entry point for structural intervention.
- On a typical day, does your nervous system feel more activated — wired, alert, scanning, difficulty settling — or more collapsed — flat, low energy, disconnected?Some people oscillate between both within the same day. Describe the pattern.Polarity read: sustained sympathetic dominance vs. dorsal vagal withdrawal — the polarity ratio has locked
- How long does it take you to genuinely settle after a stressor — not distract yourself, but actually return to regulated baseline?
- Do you startle easily, have a heightened threat response to sound or movement, or feel persistently vigilant in environments that are objectively safe?
- Do you have difficulty with transitions — moving between tasks, ending one engagement and starting another, downshifting at end of day?Autonomic flexibility: the nervous system's capacity to shift between states — low HRV is the measurable correlate
- Do you experience widespread muscular pain or tenderness not localised to a single joint or injury site?
- Do you have chronic swelling, fluid retention, or puffiness — particularly in the lower limbs, face, or hands in the morning?Pump failure: lymphatic drainage has lost its diaphragmatic engine — fluid stagnation in the web
- Is your body temperature regulation impaired — persistently cold extremities, difficulty warming up, or abnormal sweating patterns?Vascular and thyroid convergence: sympathetic dominance constricting peripheral vasculature
- Describe your energy across the day — when is it available, when does it drop, and what triggers the drop?Do you have a predictable afternoon crash? Do you get a second wind at 10pm when you should be winding down?Cortisol rhythm displacement: afternoon crash = cortisol floor; nocturnal second wind = inverted cortisol rhythm
- Does your energy depend heavily on caffeine, sugar, or food to maintain function across the day?
- Do you have difficulty recovering from exertion — exercise, illness, travel, emotional intensity? How long does recovery take?Cascade depth indicator: slow recovery indicates the system cannot efficiently complete its return cycle
- Do you wake unrefreshed even after sufficient sleep hours?
Metabolic Architecture & Blood Sugar
Insulin is the second system recruited by the cascade. Cortisol directly opposes insulin, forcing the glucose regulation system into compensation. These questions read the metabolic loop, not merely blood sugar values.
- Do you have diagnosed insulin resistance, pre-diabetes, type 2 diabetes, or metabolic syndrome?If none diagnosed: have you had fasting glucose, fasting insulin, and HbA1c measured in the past 12 months?
- Do you experience reactive hypoglycaemia — shakiness, brain fog, irritability, or weakness if you go too long without eating?Glucose instability: the body relying on counter-regulatory cortisol to maintain glucose
- Do you experience intense carbohydrate cravings, particularly in the afternoon or at night?
- What is your dietary pattern — not the ideal version, the actual pattern? Frequency of eating, primary food sources, relationship with ultra-processed foods.
- Do you notice significant mood, focus, or energy changes in direct response to what and when you eat?Glucose-brain axis: glycaemic variability directly driving neurotransmitter and autonomic instability
- Do you carry excess weight primarily in the abdomen or visceral region, or is distribution more peripheral?Visceral fat is metabolically active: produces independent inflammatory signals that maintain insulin resistance
- Do you have a history of dieting — restrictive periods, cycles of weight loss and regain, extended caloric deficit?HPA recruitment: restriction cycles are interpreted as threat events, elevating cortisol and deepening the metabolic cascade
- Do you drink alcohol? Amount, frequency, and relationship to stress or evening wind-down.Relevant to detoxification capacity and overnight glucose regulation
Fasting glucose, fasting insulin, HbA1c, HOMA-IR, hs-CRP, homocysteine, full lipid panel with particle sizing, liver enzymes (ALT, AST, GGT), ferritin, uric acid, comprehensive metabolic panel. Functional optimal ranges differ from standard laboratory reference ranges — calibrate accordingly.
Nervous System & Adrenal Function
Cortisol is the first recruited system. These questions map HPA axis function — the sympathetic-parasympathetic ratio and what the adrenal system is producing to maintain the cascade.
- What is your sleep schedule — time asleep, time waking, total hours? Consistent or variable?
- Describe your sleep quality: do you fall asleep easily, stay asleep, and wake feeling rested?
- Do you wake between 1am and 4am? This is a specific and diagnostically relevant window.Cortisol-glucose night waking: the body mobilising cortisol to counter overnight glucose drop
- Do you have diagnosed or suspected sleep apnoea? Have you had a sleep study?Cascade Stage 2 / Respiratory: sleep apnoea is a diaphragm and upper airway structural condition
- Do you experience restless legs, jaw clenching (bruxism), or vivid dreaming that disrupts rest quality?
- How do you typically respond to a moderate stressor? Describe the physiological response, not the emotional one.Adrenal output: fast ramp / slow recovery = adrenal hyper-reactivity; flat response = hypo-reactivity
- Do you feel "wired but tired" — mentally activated, possibly anxious, but physically exhausted?This specific combination is diagnostically significant.Adrenal / cortisol dissociation: cortisol rising while downstream systems deplete
- Have you had salivary cortisol, DUTCH, or any adrenal function assessment? What were the findings?
- Do you have a history of chronic anxiety, panic disorder, or PTSD?Polarity lock: the nervous system has lost capacity to complete its return cycle
- Do you experience depression, persistent low mood, or cycle between both?Polarity mapping: anxiety = sympathetic lock; depression = dorsal vagal withdrawal
Digestive System & Gut Architecture
The gut is the primary vagal target organ and the body's largest immune surface. Vagal compression at the diaphragm directly reduces parasympathetic input to gut motility, secretory function, and mucosal integrity.
- Describe your digestive function — frequency and consistency of bowel movements, ease or difficulty, variability.Functional optimal: one to three formed, easy bowel movements daily.
- Do you experience bloating, gas, or abdominal distension? When — immediately after eating, hours later, or independently of meals?Timing differential: immediate = gastric motility / enzyme issue; 2–4 hours = small intestine; evening = large bowel or SIBO
- Do you have diagnosed IBS, IBD, SIBO, GERD, or any other GI diagnosis?
- Do you have food sensitivities, intolerances, or foods that reliably produce symptoms? How many foods are currently on your avoidance list?A growing avoidance list is structural — the barrier is compromised, not the individual foods.Cascade Immune Stage: expanding food reactivity indicates gut lining integrity failure
- Have you had a course of antibiotics in the past two years? Multiple courses in the past five years?Microbiome disruption: relevant to immune surface and barrier function assessment
- Do you take or have you taken PPIs, antacids, or acid-suppressing medications regularly?Duration and whether you have ever successfully discontinued them.
- Is your stool ever pale, oily, or difficult to flush? Do you have difficulty digesting fats?Gallbladder / bile acid sufficiency: relevant to fat-soluble nutrient absorption and hormonal detox pathway
Comprehensive stool analysis with microbiome mapping, zonulin (intestinal permeability), secretory IgA, SIBO breath test (lactulose or glucose), H. pylori, B12, folate, ferritin, zinc, magnesium RBC — all impacted by absorption compromise.
Immune System & Inflammatory Architecture
The immune system is the fifth recruited system. Cortisol suppresses immune surveillance while failing to resolve inflammation — producing a body that cannot detect problems efficiently and cannot complete resolution of those it detects.
- Do you have any diagnosed autoimmune conditions? List each, the year of diagnosis, and current management.Autoimmune convergence: multiple diagnoses share the same cascade origin and barrier failure mechanism
- Do you have a family history of autoimmune conditions?
- How frequently do you get ill? Does your immune system feel overactive or underactive?
- Do you have diagnosed or suspected allergies — seasonal, environmental, food, contact?When were they first noted? Have they expanded over time?
- Do you have skin conditions — eczema, psoriasis, chronic acne, rosacea, hives, or unexplained rashes?Skin as barrier read: immune dysregulation expressed through the body's external boundary
- Do you have joint pain, joint swelling, or morning stiffness lasting more than thirty minutes?Affected joints, symmetry or asymmetry, what makes it better or worse.
- Do you have chronic pain that has been difficult to localise or explain with standard imaging?Central sensitisation: pain processing system recruited into the cascade, amplifying signal from an architectural source
- Have you had inflammatory markers measured? hs-CRP, ESR, ANA panel, thyroid antibodies?
- Have you experienced a significant viral infection from which you feel you did not fully recover?Post-viral cascade: immune system recruited and unable to resolve; structural intervention must precede immune support
Hormonal Architecture
Sex hormones are the fourth system recruited. Thyroid is the third. Both are downstream of chronic cortisol demand. These questions map the full hormonal architecture — not as a standalone endocrine assessment, but as a structural read of cascade depth.
The body produces cortisol, sex hormones, and pregnenolone from the same precursor pathway. When cortisol demand is chronically elevated, the body preferentially produces cortisol at the expense of all others. This is not a deficiency of any single hormone — it is a resource allocation decision made by a system running a sustained threat response. The intervention is structural, not supplemental.
- Do you have a diagnosed thyroid condition? Are you on thyroid medication?If on medication: dose, duration, and do you feel optimally managed or still symptomatic?
- Do you experience classic hypothyroid symptoms: persistent fatigue, cold intolerance, slow metabolism, hair loss, dry skin, brain fog, depression, puffy face?Functional hypothyroid pattern: TSH may appear normal while T4 to T3 conversion is impaired by cortisol
- Do you experience hyperthyroid or Hashimoto's fluctuation symptoms: heart palpitations, heat intolerance, tremor, anxiety, loose stools?
- Has your thyroid been assessed beyond TSH alone? Have you had free T4, free T3, reverse T3, TPO antibodies, and TgAb measured?TSH alone misses conversion impairment, subclinical Hashimoto's, and the rT3/fT3 ratio
- Has your iodine, selenium, or zinc status been assessed?Thyroid cofactors: iodine and selenium are rate-limiting for both thyroid hormone production and T4 to T3 conversion
- Describe your cycle — length, regularity, flow volume and duration, and predictable symptoms across phases.
- In the ten to fourteen days before your period, do you experience a significant shift?Luteal phase: progesterone requires a calm autonomic baseline to be produced. When the cascade is active, progesterone drops.
- Do you have diagnosed PMS, PMDD, endometriosis, fibroids, or polycystic ovaries?
- Is your flow heavy, painful, or does it include clotting?Estrogen dominance signature: heavy clot-containing flow indicates relative estrogen-progesterone imbalance — downstream of cortisol competition for pregnenolone
- Do you have signs of androgen excess — facial hair, jawline acne, scalp hair thinning, or oily skin?PCOS cascade: insulin resistance elevates LH, suppresses SHBG, and increases free androgen availability
- Have your sex hormones been measured — estradiol, progesterone, testosterone, SHBG, DHEA-S, LH, FSH?At what point in your cycle were they measured?Progesterone must be measured at cycle day 19–22 for luteal phase assessment. Follicular phase measurement is uninformative.
- Are you in perimenopause or post-menopause? How long have you been noticing changes?
- Which symptoms are most disruptive: hot flashes, night sweats, sleep disruption, mood instability, cognitive changes, vaginal dryness, joint pain, heart palpitations?
- Are your symptoms primarily fluctuating or consistently low?Fluctuating = estrogen receptor sensitivity in destabilised cascade; consistently low = deficiency compounding on cascade depth
- Are you on or have you considered hormone replacement therapy?If yes: type, delivery route, duration, and tolerance.
- Has your bone density been assessed via DEXA scan?Osteoporosis trace: estrogen withdrawal removes bone protection; cortisol actively degrades bone matrix
- Do you have symptoms of low testosterone — reduced libido, erectile difficulty, fatigue, loss of muscle mass, mood changes, reduced morning erections?
- Have you had total testosterone, free testosterone, SHBG, LH, FSH, estradiol, and DHEA-S measured?Total testosterone alone is insufficient — SHBG determines bioavailability; estradiol conversion is relevant at any age
- Do you have central adiposity — abdominal fat accumulation with relatively less in extremities?Visceral fat contains aromatase enzyme, converting testosterone to estrogen — creating a male estrogen dominance pattern
Full thyroid (TSH, fT3, fT4, rT3, TPO-Ab, TgAb). Sex hormones (estradiol, progesterone, total and free testosterone, SHBG, DHEA-S, LH, FSH, prolactin). Adrenal (DUTCH complete — includes cortisol awakening response, diurnal curve, cortisol metabolites, DHEA, sex hormone metabolites). Metabolic crossover: fasting insulin, fasting glucose, HbA1c, hs-CRP. Note: timed serum draws calibrated to cycle phase or DUTCH preferred over single time-point serum.
Structural Weight Architecture
Excess weight at the cascade Chemical level is not a behaviour problem or a willpower failure. It is a structural condition produced by a cascade of hormonal, metabolic, and autonomic loops that maintain it independent of caloric intake.
The cascade trace runs from diaphragm lock through sympathetic dominance through chronic cortisol elevation through insulin resistance through visceral fat deposition through independent inflammatory signalling — creating a self-sustaining loop. Addressing food alone without addressing the cascade is why every diet eventually fails: the loop continues operating below the level of the dietary intervention.
- At what point in your life did weight become a persistent structural feature — not a temporary gain, but a pattern you have not been able to resolve through normal effort?Onset mapping: typically anchors at puberty, significant stressor, pregnancy, prolonged restriction, or period of crisis
- What have you already tried? What produced short-term results but did not hold?The pattern of what worked and failed structurally reveals the specific loops maintaining the condition.
- Do you lose weight when restricting but regain it — and more — within weeks or months of stopping?Snapback pattern: the cascade loop re-establishing its structural set point
- Have you done extended fasting protocols — OMAD, 24-hour fasts, multi-day fasting? What was the physiological response?Extended fasting elevates cortisol significantly. In an active cascade, fasting is likely worsening the primary driver.
- Do you gain weight easily but lose it very slowly, even with significant dietary restriction or exercise?Thyroid and insulin loop: both actively suppressing basal metabolic rate and promoting storage
- Where does excess weight predominantly accumulate?Central/abdominal: cortisol and insulin dominant. Hips and thighs: estrogen dominant. Proportionally distributed: less likely to be hormonally driven.
- Do you experience significant fluid retention — weight fluctuating by more than 2–3kg across the week independent of dietary intake?Aldosterone and cortisol-driven fluid retention is often misread as fat mass; lymphatic pump failure sustains it
- Have you been tested for insulin resistance specifically — not just fasting glucose but fasting insulin and HOMA-IR?
- Have you used GLP-1 receptor agonists (Ozempic, Wegovy, Mounjaro) or are you considering them?If yes: what was the result? Did weight return upon cessation?GLP-1 medications act on appetite signalling and gastric emptying. They do not address the structural cascade.
- What is your relationship with food in terms of emotional use — does stress, anxiety, or particular emotional states drive eating independent of hunger?EA structural read: food as containment — using intake to regulate an autonomic system that cannot self-regulate due to cascade
- Do you eat past fullness regularly? Do you feel hunger signals are clear, absent, or difficult to distinguish from emotional states?Interoceptive disruption: hunger, satiety, and emotional states are all interoceptive signals — all are distorted when the autonomic system is in chronic cascade
- Does your weight feel connected to a particular period of life, a relationship dynamic, or a phase of identity?Not the story about it. The structural link you have already sensed.EA pattern read: weight as structural encoding of a pattern that has not yet been redesigned
- Do you have a sense that your weight serves a function — protection, boundary, visibility regulation?This is not an affirmation prompt. The body is precise. If weight is structurally persistent, there is a structural reason.
- How does your weight respond to significant life changes — a move, a relationship change, a period of creative expansion, or a period of loss?Field-structure correlation: if weight tracks life architecture events rather than dietary changes, the pattern is operating at a structural level
Fasting insulin and fasting glucose (HOMA-IR). HbA1c. Full thyroid panel (TSH, fT3, fT4, rT3). DHEA-S and morning cortisol (or DUTCH). Comprehensive lipids with particle sizing. Liver function (ALT, AST, GGT — GGT is sensitive early NAFLD marker). Ferritin. Full sex hormone panel. Leptin and adiponectin if available. Uric acid. hs-CRP. Vitamin D, magnesium RBC, zinc. Body composition via DEXA preferred over BMI.
Structural Pattern & Life Architecture
These questions complete the diagnostic by reading the life architecture alongside the biological one. The cascade does not operate only in the body — it operates in the design of the life.
- What is the repeating pattern you keep arriving at — in your health, your relationships, your work, your sense of self?Not the story. The structure underneath the story.
- If you have ever made significant progress, what is the mechanism by which it reverted?Not the event — the structural sequence of the reversion.Snapback map: reveals the specific recursion loop maintaining the pattern's set point
- What are you producing in your life right now that you did not consciously choose?
- Where in your life does structure exist and feel stable? Where is it absent or constantly collapsing?Containment-flow read: zones where structure holds vs. fails map the polarity bias operating in the life architecture
- What do you tolerate in your current life that is structurally incompatible with what you are trying to build?
- When you imagine yourself without the primary pattern — what is present? Not the relief of its absence. What is underneath it.
- What do you know about yourself that you have not yet been willing to act from?Not an affirmation. A structural truth you are aware of but are not yet living.
- What has been consistent in your life across all the change — the thing that has not shifted regardless of what you have done externally?Signal identification: what remains constant under all distortion is the closest thing to structural signal available in the intake
- What would it mean — structurally, not emotionally — if this pattern resolved? What would have to be true about your life that is currently not true?
- What is one thing you already know about your structure that no practitioner has confirmed or addressed?
- Is there anything you did not share in this intake that is structurally relevant?
This diagnostic framework is a practitioner reference for use within the Elegant Alchemy methodology and a qualified Functional Medicine clinical context. It does not constitute medical advice and does not replace standard clinical assessment.
Hormonal Architecture & Weight
These follow-up modules are used when the initial intake reveals Chemical or Immune cascade depth, or when hormonal dysregulation or metabolic resistance is a primary presenting pattern. They are not part of the initial session — they deepen a picture already begun.
The body produces cortisol, sex hormones, and pregnenolone from the same precursor pathway. When cortisol demand is chronically elevated, the body preferentially produces cortisol at the expense of all others. This is not a deficiency of any single hormone — it is a resource allocation decision made by a system running a sustained threat response. The intervention is structural, not supplemental.
Thyroid Function
The thyroid is the third system recruited by the cascade. Cortisol directly impairs T4 to T3 conversion, producing functional hypothyroid patterns even when TSH appears normal. These questions establish the functional picture before labs are reviewed.
- Do you have a diagnosed thyroid condition — hypothyroidism, hyperthyroidism, Hashimoto's, Graves'?Are you on thyroid medication? If yes: dose, how long, and do you feel optimally managed or still symptomatic?
- Has your thyroid been assessed beyond TSH alone?Have you had free T4, free T3, reverse T3, TPO antibodies, and TgAb measured?TSH alone misses conversion impairment, subclinical Hashimoto's, and the rT3/fT3 ratio that reflects HPA-thyroid axis interaction
- Do you have a family history of thyroid conditions?
- Do you experience persistent fatigue that is not relieved by sleep?Functional hypothyroid: metabolic rate suppressed at chemical cascade level
- Do you have cold intolerance — persistently cold hands and feet, difficulty warming up, or need for more layers than others around you?
- Do you experience hair loss or thinning — including eyebrows, particularly the outer third?Outer third eyebrow loss is a specific hypothyroid indicator
- Do you have dry skin, brittle nails, or puffiness particularly in the face and around the eyes on waking?
- Do you experience brain fog, slow thinking, or difficulty retrieving words?
- Do you have constipation as a consistent pattern, independent of dietary intake?Gut motility is thyroid-dependent — constipation is a functional hypothyroid marker
- Has your weight been resistant to change even with dietary restriction and exercise?Basal metabolic rate is directly governed by thyroid output — weight resistance is a downstream cascade expression
- Do you experience heart palpitations — a fluttering, racing, or irregular heartbeat not explained by other causes?
- Do you have heat intolerance — difficulty tolerating warmth that others find comfortable?
- Do you experience unexplained anxiety, tremor, or difficulty with stillness?Distinguishing thyroid-driven anxiety from HPA-driven anxiety: thyroid anxiety is typically accompanied by physical tremor and heat intolerance
- Have you had periods of unexplained weight loss despite normal or increased appetite?
- Have you experienced loose stools or increased bowel frequency as a consistent pattern?
- Has your iodine, selenium, or zinc status been assessed?Iodine and selenium are rate-limiting for both thyroid hormone production and T4→T3 conversion. Zinc is required for TSH receptor function.
- Do you eat seafood and sea vegetables regularly, or have you avoided iodised salt?
- Have you ever taken high-dose iodine supplementation? Any response — positive or adverse?High-dose iodine can trigger Hashimoto's flare in susceptible individuals — clinically significant history
TSH, free T4, free T3, reverse T3, rT3/fT3 ratio, TPO antibodies (TPO-Ab), thyroglobulin antibodies (TgAb), thyroid ultrasound if goiter or nodule suspected. Nutritional: selenium (serum or RBC), zinc (RBC), iodine (spot urine). Note: standard laboratory reference ranges for TSH (0.5–4.5) are not functional optimal ranges — assess at 1.0–2.0 for symptomatic clients.
Sex Hormones — Cycling Physiology
Sex hormones are the fourth recruited system. Progesterone is the first to fall when cortisol demand is elevated — it shares the same precursor pathway and is sacrificed first. These questions establish the functional hormonal picture across the full cycle.
- Describe your cycle — typical length, regularity, flow volume and duration, and any predictable physical symptoms across phases.
- Has your cycle changed over the past two to three years — shorter, longer, more erratic, heavier, or lighter?Cycle changes map when the cascade deepened to Chemical level — the timeline is diagnostically significant
- Do you have diagnosed PMS, PMDD, endometriosis, fibroids, or polycystic ovaries?When were these diagnosed? What is the current management?
- Are you currently on hormonal contraception?If yes: type, duration, and reason for use — contraception, cycle management, or symptom suppression.Hormonal contraception suppresses natural cycle — all hormonal assessment below will require a 3–6 month washout period after cessation for accurate baseline
- In the ten to fourteen days before your period, how significant is the shift from your follicular baseline?Rate the change: minimal, moderate, significant, or severe enough to disrupt daily function.Severity of luteal phase shift is a direct indicator of progesterone deficiency depth
- What symptoms specifically appear or worsen in the luteal phase?Mood changes, anxiety, depression, rage, brain fog, bloating, breast tenderness, insomnia, cravings, headaches, pelvic pain.
- Do your symptoms appear immediately after ovulation (day 14–16) or closer to menstruation (day 24–28)?Early onset (day 14–16) indicates low progesterone production. Late onset (day 24–28) may indicate estrogen withdrawal rather than progesterone deficiency — different intervention.
- Does physical or emotional stress reliably worsen your luteal phase symptoms?Stress → cortisol → progesterone steal: direct cascade confirmation
- Is your flow heavy, painful, or does it include clotting?Heavy clot-containing flow with painful cramping indicates relative estrogen-progesterone imbalance — downstream of cortisol competition for pregnenolone
- Do you have fibrocystic breasts or breast tenderness independent of the premenstrual window?
- Do you experience fluid retention, bloating, or weight fluctuation that tracks your cycle?
- Do you have a history of fibroids or endometriosis?Both are estrogen-dependent conditions — their presence confirms sustained estrogen dominance
- Do you use plastics, conventional personal care products, or have significant environmental chemical exposure?Xenoestrogens load the estrogen receptor — relevant to total estrogenic burden, not just endogenous production
- Do you have facial or body hair in a male-pattern distribution — chin, upper lip, chest, abdomen?
- Do you experience acne along the jawline and chin specifically?Jawline acne is androgen-driven — distinguishable from inflammatory or gut-driven acne by distribution
- Do you have scalp hair thinning — particularly at the crown or temples?
- Have you been diagnosed with PCOS?If yes: what type — insulin-driven, adrenal, inflammatory, or post-pill?PCOS is not one condition — type determines the cascade entry point and intervention sequence
- Do you have difficulty conceiving or a history of miscarriage?Progesterone deficiency and chronic sympathetic dominance directly impair implantation and early pregnancy maintenance
- Are you currently pregnant, postpartum, or breastfeeding?If recently postpartum: within how many months? Were there pregnancy complications?
- Did your hormonal or health picture shift significantly after a pregnancy — even years later?Postpartum hormonal reorganisation can lock cascade patterns that were previously episodic
Estradiol, progesterone, LH, FSH — timed to cycle day 19–22 for luteal assessment (progesterone measured here is the most diagnostically informative). Total testosterone, free testosterone, SHBG, DHEA-S, prolactin, androstenedione. Estrogen metabolism: DUTCH Complete (includes cortisol awakening response, diurnal cortisol, sex hormone metabolites, estrogen metabolism pathway — 2-OH, 4-OH, 16-OH ratios). Liver function (estrogen clearance): ALT, AST, GGT.
Perimenopause & Menopause
The cascade does not produce menopause. It amplifies the structural disruption the transition creates. A woman entering perimenopause with an already-active cascade will experience a qualitatively different and more severe transition than one whose structural architecture is intact.
- Are you in perimenopause or post-menopause? If perimenopause, how long have you been noticing changes?What was the first symptom that prompted you to identify this phase?
- Are your symptoms primarily fluctuating or consistently low?Fluctuating = typical of perimenopause, estrogen variability. Consistently low = post-menopause, estrogen deficiency.Phase-specific read: fluctuating = estrogen receptor sensitivity in destabilised cascade; consistently low = deficiency compounding on pre-existing cascade depth
- What age did you enter perimenopause? Is this earlier than your mother or sisters?Early perimenopause (before 45) is associated with chronic HPA activation — the cascade accelerating the transition
- Which symptoms are most disruptive?Hot flashes, night sweats, sleep disruption, mood instability, cognitive changes (word finding, memory), vaginal dryness, joint pain, fatigue, weight changes, heart palpitations, skin changes.
- When do hot flashes and night sweats occur — day, night, or both? What triggers them?Timing and triggers map the autonomic pattern driving vasomotor symptoms — stress-triggered flashes indicate sympathetic dominance as the primary driver
- Have you experienced significant cognitive changes — word finding, memory, processing speed — that feel qualitatively different from previous baseline?Estrogen and progesterone are neuroprotective. Withdrawal in the context of an already-running cascade accelerates neuroinflammatory signalling.
- Has your sleep architecture changed independently of night sweats?Difficulty falling asleep, waking between 1am and 4am, reduced dream recall, unrefreshing sleep.
- Have your cardiovascular risk markers changed since entering perimenopause — blood pressure, lipids, fasting glucose?
- Are you currently on or have you considered hormone replacement therapy?If yes: type (bioidentical vs. synthetic), delivery route (transdermal, oral, vaginal), dose, duration, and how you are tolerating it.Transdermal bioidentical estradiol has a different cardiovascular and metabolic risk profile from oral synthetic estrogen — distinguish clearly
- Have you had a conversation with a practitioner about HRT and been declined or discouraged?What was the stated reason?
- Are you using any over-the-counter or herbal interventions for perimenopausal symptoms?Black cohosh, red clover, progesterone cream, DHEA, evening primrose.
- Has your bone density been assessed via DEXA scan? If so, what were the results and when?Estrogen withdrawal removes bone protection; cortisol actively degrades bone matrix; testosterone loss removes bone synthesis stimulus
- Do you have a history of stress fractures, early onset bone loss, or a family history of osteoporosis?
- Has your lipid profile changed since entering perimenopause?Estrogen maintains HDL and suppresses LDL — withdrawal commonly produces an adverse lipid shift
Estradiol (E2), FSH, LH, progesterone, total and free testosterone, SHBG, DHEA-S. DUTCH Complete for full hormone and cortisol metabolite picture. Bone: DEXA scan, vitamin D (25-OH), calcium, magnesium RBC, bone resorption markers (NTx, CTx). Cardiovascular: full lipid panel with particle sizing, hs-CRP, fasting insulin, fasting glucose, homocysteine. Thyroid full panel — frequently shifts in perimenopause.
Male Hormonal Architecture
The same cascade applies — cortisol competing for pregnenolone suppresses testosterone production. Visceral fat compounds the problem by converting testosterone to estrogen via aromatase. These questions map the male hormonal picture within the cascade framework.
- Do you have symptoms of low testosterone — reduced libido, erectile difficulty, fatigue, loss of muscle mass, difficulty with recovery from training, mood changes, or reduced motivation?
- Have you noticed reduced morning erections, or a change in frequency?Morning erections are regulated by testosterone — their absence or reduction is a sensitive low-T indicator
- Have you had total testosterone, free testosterone, SHBG, LH, FSH, and estradiol measured?Total testosterone alone is insufficient — SHBG determines bioavailability; estradiol from aromatisation is relevant at any age
- At what time of day was your testosterone tested?Testosterone peaks between 7am and 9am — afternoon testing produces artificially low results
- Do you carry excess weight centrally — abdomen and waist — with relatively less in the extremities?Visceral fat contains aromatase enzyme, converting testosterone to estrogen — creating male estrogen dominance that further suppresses testosterone production
- Do you have breast tissue development or tenderness?Gynecomastia: estrogen accumulation from aromatisation or external exposure
- Do you use plastics, alcohol regularly, or have significant environmental or occupational chemical exposure?Xenoestrogens, alcohol, and certain industrial chemicals all suppress testosterone and/or increase aromatisation
- Are you on or have you been on testosterone replacement therapy (TRT)?If yes: delivery method, dose, duration, and whether you use an aromatase inhibitor.Exogenous testosterone suppresses LH and FSH — testicular atrophy and fertility impairment occur without HCG co-administration
- Have you used anabolic steroids — prescribed or otherwise?Duration, compounds used, and whether a post-cycle protocol was completed.
Total testosterone (fasting, 7–9am), free testosterone (calculated or equilibrium dialysis), SHBG, LH, FSH, estradiol (sensitive assay), DHEA-S, prolactin. PSA if over 40 or before initiating TRT. Metabolic crossover: fasting insulin, fasting glucose, HbA1c, hs-CRP, comprehensive lipid panel. Full thyroid panel. Note: functional optimal for total testosterone is 600–900 ng/dL in most men — standard laboratory lower limit of 300 ng/dL is not a functional optimal reference.
Structural Weight Architecture
Excess weight at the cascade Chemical level is not a behaviour problem or a willpower failure. It is a structural condition produced by a cascade of hormonal, metabolic, and autonomic loops that maintain it independent of caloric intake. These questions map the structural drivers.
The cascade trace runs from diaphragm lock through sympathetic dominance through chronic cortisol elevation through insulin resistance through visceral fat deposition through independent inflammatory signalling — creating a self-sustaining loop. Addressing food alone without addressing the cascade is why every diet eventually fails: the loop producing the weight continues operating below the level of the dietary intervention.
- At what point in your life did weight become a persistent structural feature — not a temporary gain, but a pattern you have not been able to resolve through normal effort?Onset mapping: typically anchors at puberty, a significant stressor, pregnancy, a period of prolonged restriction, or a period of crisis
- What have you already tried — diets, protocols, exercise programmes, medications?What produced short-term results but did not hold? What produced no results at all?
- Do you lose weight when you restrict calories but regain it — and more — within weeks or months of stopping?Snapback pattern: the cascade loop re-establishing its structural set point
- Have you done extended fasting protocols — OMAD, 24-hour fasts, multi-day fasting?What was the physiological response?Extended fasting elevates cortisol significantly — in a client with active cascade, fasting is likely worsening the primary driver
- Do you gain weight easily but lose it very slowly — even with significant dietary restriction or exercise?Thyroid and insulin loop: both suppressing basal metabolic rate and promoting storage
- Where does excess weight predominantly accumulate?Central/abdominal: cortisol and insulin dominant. Hips and thighs: estrogen dominant. Upper back and arms: less hormonally specific. Proportionally distributed: less likely to be hormonally driven.Distribution maps which recruited system carries the highest load
- Do you experience significant fluid retention — weight fluctuating by more than 2–3kg across the week independent of dietary intake?Aldosterone and cortisol-driven fluid retention is often misread as fat mass; lymphatic pump failure sustains it
- Have you been tested for insulin resistance specifically — fasting insulin and HOMA-IR, not just fasting glucose?
- Have you been tested for hypothyroidism with a full panel beyond TSH alone?
- Have you used GLP-1 receptor agonists — Ozempic, Wegovy, Mounjaro — or are you considering them?If yes: what was the result? Did appetite suppression occur? Did weight return upon cessation?GLP-1 medications act on appetite signalling and gastric emptying. They do not address the structural cascade. Assess what the medication can and cannot do within this client's specific structural architecture.
- Do you have non-alcoholic fatty liver disease (NAFLD) or elevated liver enzymes on bloodwork?Visceral fat deposits ectopically in the liver early in insulin resistance progression — NAFLD is a cascade marker at the Chemical-to-Organ transition
- What is your relationship with food in terms of emotional use?Does stress, anxiety, loneliness, or a particular emotional state drive eating independent of hunger?EA structural read: food as containment — using intake to regulate an autonomic system that cannot self-regulate due to cascade. Not a psychological failing — the body seeking any available regulatory input when its own regulatory architecture is offline.
- Do you eat past fullness regularly? Are hunger signals clear, or difficult to distinguish from emotional states?Interoceptive disruption: hunger, satiety, and emotional states are all interoceptive signals — all are distorted when the autonomic system is in chronic cascade
- Does your weight feel connected — in your own understanding — to a particular period of life, a relationship dynamic, or a phase of identity?Not the story about it. The structural link you have already sensed.EA pattern read: weight as structural encoding of a pattern that has not yet been redesigned
- Do you have a sense that your weight serves a function — protection, boundary, visibility regulation?The body is precise. If weight is structurally persistent, there is a structural reason.
- How does your weight respond to significant life changes — a move, a relationship change, a period of creative expansion, or a period of loss?Field-structure correlation: if weight tracks life architecture events rather than dietary changes, the pattern is operating at a structural level that predates and governs the metabolic expression
Fasting insulin and fasting glucose (calculate HOMA-IR). HbA1c. Full thyroid panel (TSH, fT3, fT4, rT3). DHEA-S and morning cortisol (or DUTCH Complete). Comprehensive lipids with particle sizing. Liver function (ALT, AST, GGT — GGT is a sensitive early NAFLD marker). Ferritin (elevated in insulin resistance). Full sex hormone panel. Leptin and adiponectin if available. Uric acid. hs-CRP. Vitamin D (25-OH), magnesium RBC, zinc. Body composition via DEXA — distinguishes fat mass, lean mass, and visceral versus subcutaneous fat. BMI alone is clinically insufficient.
Comprehensive Lab Reference
A consolidated reference for the full hormonal and metabolic panel. Order selectively based on the cascade depth and recruited systems identified in the initial intake.
- ThyroidTSH, free T3, free T4, reverse T3, rT3/fT3 ratio, TPO-Ab, TgAb, thyroid ultrasound if indicated
- Female Sex HormonesEstradiol, progesterone (timed cycle day 19–22), LH, FSH, total testosterone, free testosterone, SHBG, DHEA-S, prolactin, androstenedione
- Male Sex HormonesTotal testosterone (7–9am fasting), free testosterone, SHBG, LH, FSH, estradiol (sensitive assay), DHEA-S, prolactin, PSA (if over 40)
- Adrenal / HPADUTCH Complete (diurnal cortisol x4, cortisol awakening response, cortisol metabolites, DHEA, sex hormone metabolites, estrogen metabolism pathways)
- Glucose & InsulinFasting glucose, fasting insulin, HbA1c, HOMA-IR calculation, post-prandial glucose if reactive hypoglycaemia suspected
- LipidsFull lipid panel with LDL particle sizing (LDL-P), HDL, triglycerides, Lp(a)
- Liver & InflammationALT, AST, GGT, hs-CRP, homocysteine, ferritin, uric acid
- NutritionalVitamin D (25-OH), magnesium RBC, zinc RBC, selenium, B12, folate, iron studies
- Body CompositionDEXA scan: total fat mass, lean mass, visceral adipose tissue (VAT), bone mineral density
These follow-up modules are for use within a qualified Functional Medicine and Elegant Alchemy methodology context. They do not constitute medical advice and do not replace standard clinical assessment or laboratory interpretation by a licensed practitioner.