Name *

First Name

Last Name

Headache

0

1

2

3

4

Faintness

0

1

2

3

4

Dizziness

0

1

2

3

4

Insomnia

0

1

2

3

4

Stuffy nose

0

1

2

3

4

Sinus problems

0

1

2

3

4

Hay fever

0

1

2

3

4

Sneezing attacks

0

1

2

3

4

Excessive mucus formation

0

1

2

3

4

Chronic coughing

0

1

2

3

4

Gagging or frequent need to clear throat

0

1

2

3

4

Sore throat, hoarseness, or loss of voice

0

1

2

3

4

Swollen or discolored tongue, gums, or lips

0

1

2

3

4

Toothache or gum pain or new dental work

0

1

2

3

4

Canker sores

0

1

2

3

4

Acne

0

1

2

3

4

Hives or other allergic breakout

0

1

2

3

4

Rash or persistently dry skin

0

1

2

3

4

Hair loss

0

1

2

3

4

Flushing or hot flashes

0

1

2

3

4

Frequently feel cold

0

1

2

3

4

Excessive sweating

0

1

2

3

4

Part of body feeling numb

0

1

2

3

4

Irregular or skipped heartbeat

0

1

2

3

4

Rapid or pounding heartbeat

0

1

2

3

4

Chest pain

0

1

2

3

4

Chest congestion

0

1

2

3

4

Asthma, bronchitis

0

1

2

3

4

Shortness of breath

0

1

2

3

4

Difficulty breathing

0

1

2

3

4

Nausea or vomiting

0

1

2

3

4

Diarrhea

0

1

2

3

4

Constipation

0

1

2

3

4

Bloated feeling

0

1

2

3

4

Belching, burping

0

1

2

3

4

Passing gas, flatulence

0

1

2

3

4

Heartburn

0

1

2

3

4

Intestinal or stomach pain

Please describe which in the digestion comments section below

0

1

2

3

4

Other pain in the GI tract

Please describe where in the digestion comments section below

0

1

2

3

4

Pain or aches in joints

0

1

2

3

4

Arthritis

0

1

2

3

4

Stiffness or limitation of movement

0

1

2

3

4

Pain or aches in muscles

0

1

2

3

4

Tremor or restless leg

0

1

2

3

4

Feeling of weakness or tiredness

0

1

2

3

4

Binge eating/drinking

0

1

2

3

4

Craving certain foods

0

1

2

3

4

Excessive weight

0

1

2

3

4

Compulsive eating

0

1

2

3

4

Water retention

0

1

2

3

4

Underweight

0

1

2

3

4

Fatigue, sluggishness

0

1

2

3

4

Apathy, lethargy

0

1

2

3

4

Hyperactivity

0

1

2

3

4

Restlessness

0

1

2

3

4

Poor memory

0

1

2

3

4

Confusion, poor comprehension

0

1

2

3

4

Poor concentration or focus

0

1

2

3

4

Poor physical coordination

0

1

2

3

4

Difficulty in making decisions

0

1

2

3

4

Stuttering or stammering

0

1

2

3

4

Learning disabilities

0

1

2

3

4

Mood swings

0

1

2

3

4

Anxiety, fear, nervousness

0

1

2

3

4

Anger, irritability, aggressiveness

0

1

2

3

4

Depression

0

1

2

3

4

Other mood challenges

Option 1

Option 2

Frequent illness

0

1

2

3

4

Frequent or urgent urination

0

1

2

3

4

Inability to urinate or low urine flow

0

1

2

3

4

Low libido or other sexual dysfunction

0

1

2

3

4

Genital itch or discharge

0

1

2

3

4

Women: Breast fibroids

0

1

2

3

4

Women: Painful or tender breasts

0

1

2

3

4

Women: Uterine/Ovarian fibroids

0

1

2

3

4

Other

0

1

2

3

4