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NAME |
_______ |
_______________________ |
DATE |
_______ |
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Rate each of the following symptoms based upon your typical health profile (For the past 30 days): |
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Point Scale |
0 |
Never or almost never have the symptom |
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1 |
Occasionally have it, effect is not severe |
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2 |
Ocasionally have it, effect is severe |
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3 |
Frequently have it, effect is not severe |
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4
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Frequently have it, effect is severe |
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HEAD |
________ |
Headaches |
DIGESTIVE TRACT |
________ |
Nausea, vomiting |
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________ |
Faintness |
________ |
Diarrhea |
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________ |
Dizziness |
________ |
Constipation |
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________ |
Insomnia |
________ |
Bloated feeling |
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_______ |
TOTAL |
________ |
Belching, passing gas |
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________ |
Heartburn |
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EYES |
________ |
Watery or itchy eyes |
________ |
Intestinal/stomach pain |
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________ |
Swollen, reddened or sticky eyelids |
_______ |
TOTAL |
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________ |
Bags or dark circles under eyes |
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________ |
Blurred or tunnel vision |
JOINTS / MUSCLE |
________ |
Pain or aches in joints |
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(does not include near-or far-sightedness) |
________ |
Arthritis |
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________ |
TOTAL |
________ |
Stiffness or limitation of movement |
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________ |
Pain or aches in muscles |
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________ |
Feeling of weakness or tiredness |
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EARS |
________ |
Itchy ears |
_______ |
TOTAL |
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________ |
Earaches, ear infections |
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________ |
Drainage from ear |
WEIGHT |
________ |
Binge eating/drinking |
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________ |
Ringing in ears, hearing loss |
________ |
Craving certain foods |
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_______ |
TOTAL |
________ |
Excessive weight |
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________ |
Compulsive eating |
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NOSE |
________ |
Stuffy nose |
________ |
Water retention |
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________ |
Sinus problems |
________ |
Underweight |
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________ |
Hay fever |
_______ |
TOTAL |
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________ |
Sneezing attacks |
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________ |
Excessive mucus formation |
ENERGY / ACTIVITY |
________ |
Fatigue, sluggishness |
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_______ |
TOTAL |
________ |
Apathy, lethargy |
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________ |
Hyperactivity |
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MOUTH/ THROAT |
________ |
Chronic coughing |
________ |
Restlessness |
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________ |
Gagging, frequent need to clear throat |
_______ |
TOTAL |
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________ |
Sore throat, hoarseness, loss of voice |
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________ |
Swollen or discolored tongue, gums or lips |
MIND |
________ |
Poor memory |
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Canker sores |
________ |
Confusion, poor comprehension |
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_______ |
TOTAL |
________ |
Poor concentration |
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________ |
Poor physical coordination |
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________ |
Difficulty in making decisions |
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SKIN |
________ |
Acne |
________ |
Stuttering or stammering |
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________ |
Hives, rashes, dry skin |
________ |
Slurred speech |
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________ |
Hair loss |
________ |
Learning disabilities |
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________ |
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_______ |
TOTAL |
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________ |
Excessive sweating |
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_______ |
TOTAL |
EMOTIONS |
________ |
Mood swings |
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________ |
Anxiety, fear, nervousness |
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HEART |
________ |
Irregular or skipped heartbeat |
________ |
Anger, irritability, aggressiveness |
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________ |
Rapid or pounding heartbeat |
________ |
Depression |
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________ |
Chest pain |
_______ |
TOTAL |
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_______ |
TOTAL |
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OTHER |
________ |
Frequent illness |
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LUNGS |
________ |
Chest congestion |
________ |
Frequent or urgent urination |
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________ |
Asthma, bronchitis |
________ |
Genital itch or discharge |
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________ |
Shortness of breath |
_______ |
TOTAL |
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________ |
Difficulty breathing |
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_______ |
TOTAL |
GRAND TOTAL |
_________ |
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Chart courtesy of Adam Banning
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