You are on page 1of 1

Name

PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

Digestion Sleep Genitourinary


__nausea __insomnia S __kidney problems
__vomiting __sleep disorder __urinary tract
__diarrhea __sleep apnea S __bladder
__constipation __snoring __yeast infections (chronic) S
__bloated feeling __frequent/urgent urination
__stomach pains __genital itch/discharge
__stomach cramps Heart
__heart burn __Irregular/Skipped Heartbeat S Mouth & Throat
__blood in stool S __Rapid/Pounding Heartbeat S __chronic coughing
__ mucous in stool __Chest Pain S __gagging/clearing throat often
__IBS (Irritable bowel syndrome) S __Congestive Heart Failure S __sore throat/hoarse voice/voice loss
__Crohn's Disease S __swollen/discolored tongue/lips
__Ulcerative Colitis S __canker sores
__anal itching Joints & Muscles __itching on roof of mouth
__pains/aches in joints
Ears __osteoarthritis Nose
__itchy ears __stiffness/limited movement __stuffy nose
__ear aches/ear infections S __pain/aches in muscles __chronically red/inflamed nose
__drainage from ear __feeling weak/tired __sinus problems
__ringing in ears __swollen/tender joints S __hay fever
__hearing loss __growing pains in legs __sneezing attacks
__reddening of ears __Psoriatic Arthritis S __excessive mucous formation
__Gout S
Emotions __Rheumatoid Arthritis S Skin
__mood swings __acne
__Bipolar Disorder S Lungs __itching
__anxiety __chest congestion __hives/rash/dry skin
__fear __bronchitis (chronic) S __hair loss
__nervousness __shortness of breath __flushing/hot flashes
__anger __difficulty breathing __Psoriasis S
__irritability __persistent cough __Eczema S
__aggressiveness __wheezing
__argumentative __Asthma S Weight
__frustrated __binge eating/drinking
__cry easily __craving certain foods
__Depression S Mind __excessive weight
__poor memory __compulsive eating
Eyes __difficulty completing projects __water retention
__watery eyes __difficulty with mathematics __underweight
__itchy eyes __underachiever
__red eyes __poor/short attention span Other Conditions
__swollen eyelids or bags __confusion __Autism S
__dark circles under eyes __easily distracted __Auto Immune Disorder(s) S
__blurred vision __difficulty making decisions __Chronic Fatigue S
__tunnel vision __mild learning Disabilities __Multiple Chemical Sensitivities S
__A.D.H.D. S __Diabetic S
Head __A.D.D. S __Obsessive Compulsive Disorder S
__headaches __frequent illness S
__migraines S __Other________________________
__faintness _______________________________
__dizziness _______________________________
__light headedness _______________________________
__facial flushing