Name
*
First Name
Last Name
Age
*
Date
MM
DD
YYYY
General fatigue or weakness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Difficulty losing weight
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent illness/infections
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High stress lifestyle
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Smoking
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Drinking more than 2 cups of coffee/day
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bad breath and/or body odour
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Constipation
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bags under eyes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Crave sugars, bread, alcohol
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Difficulty digesting certain foods
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Have used antibiotics in past 10 years
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Allergies
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Poor concentration or memory
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Belching or burping after meals
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Skin/complexion problems
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent consumption of red meat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Regular use of dairy products
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heavy alcohol consumption
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Exposure to toxins/chemicals
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent mood swings
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Depressed and/or irritable
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Brittle fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dry, brittle hair, split ends
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High fat/high cholesterol diet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nervousness/anxiety/tension/worry
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Insomnia/restless sleep
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Low fibre diet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscle cramps
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sleepy when sitting up
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: menstrual cramps
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bronchitis/asthma/pneumonia/emphysema
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cellulite
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cold hands and feet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Varicose veins
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Feeling out of control
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Food/chemical sensitivities
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent yeast/fungus problems
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bones break easily, osteoporosis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Too little exercise
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive mucous
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Short of breath climbing stairs
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tingling in lips, fingers, arms, legs
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Chest pains
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Very rapid or slow heart beat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Painful, hard or thin bowel movements
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Alternating constipation/diarrhea
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Recurrent bladder infections
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: Menopause, hot flashes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: PMS
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Difficult urination
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Swollen glands, puffy throat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lower abdominal pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent need to urinate
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Joint pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sinus inflammation/discharge
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Arthritis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sudden weight gain/loss
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Headaches/Migraines
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: Taking birth control pills
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lower back pains
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dry, flaky skin
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Drink less than 6 glasses of fluids/day
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Water retention
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Low sex drive
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Feeling heavy/bloated after meals
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Chronic cough
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive gas, belching or burping after meals
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Stomach bloated after eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sleepy after eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Longitudinal striations on fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Eat when rushed/in a hurry
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Halitosis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Full feeling after heavy meat meal
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heavy, tired feeling after eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nausea after taking supplements
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Acne
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Undigested food in the stool
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Yellow or pale fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Skin oily on nose and forehead
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Fats/greasy foods cause nausea, headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Vertical white streaks on fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Onions, cabbage, radishes, cucumbers cause bloating /gas
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bad breath; bad taste in mouth
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excess body odour
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High cholesterol/high cholesterol diet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Migraine headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Discomfort underneath right ribcage
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Food allergies
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Irritable, easily angered
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Weight gain around the abdomen
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Yellow palms
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Jaundice
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Poor concentration
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Difficulty losing weight
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Acne, boils, rashes, psoriasis or eczema
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Constipation
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gall stones; history of gall stones
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Stool appears clay-coloured, foul odoured
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Constipation
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High cholesterol diet; High blood cholesterol levels
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Severe pain in right upper abdomen
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Stomach pain 1 hour after eating or at night
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Burning sensation in stomach
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain aggravated by worry/tension
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hiatal hernia
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gastritis, gastric ulcer
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nausea, vomiting
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sensation of acidity in abdominal area
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heartburn, indigestion
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Blood in stool
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lower back pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Long term aspirin use
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Severe abdominal pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nausea and vomiting
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Slow digestion; feel full for hours after eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Fever
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Alcohol addiction
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Jaundice
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hungry up to 3 hours after eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Strong, sudden cravings for sweets, starches coffee or alcohol
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nervous/anxious feelings relieved by eating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Irritable if late for or skip a meal
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Overweight
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Addicted to coffee with sugar and/or colas
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent “midnight snacks”
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Family history of diabetes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Fatigue
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Fainting spells
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Depression
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lose temper easily
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Extreme fatigue
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Recurrent vaginal infections
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent use of antibiotics
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
White coated tongue, oral thrush
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Crave sugars, bread, alcohol
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tonsillitis, recurrent strep throat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Itchy, watery or dry eyes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Skin flushes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Chronic indigestion, frequently use antacids
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Always cold, especially in extremities
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: PMS
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in pelvic area
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Abdominal gas and bloating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Loss of sex drive
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cystitis, repeated bladder infection
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Increasing food and chemical sensitivities; severe reaction to
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: endometriosis/ovary problems
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Chronic diarrhea
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hives, psoriasis, acne, skin rashes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Rectal itching
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Abnormal muscle aches from exercise
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive wax in ears
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Unexpected/unexplained weight gain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Impotence
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Athlete’s foot, finger/toenail fungus, ringworm
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Jock itch
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
“Brain fog”
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Irritability
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Memory loss
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Mental confusion
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Depression or anger for no reason
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Anxiety/panic attacks
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Inability to concentrate
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Phobic/compulsive
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lethargy
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Mood swings
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Itchy ears, nose, anus
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Forgetfulness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Slow reflexes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gas and bloating
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Unclear thinking
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Loss of appetite
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Yellowish or pale face
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Fast heartbeat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heart pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in navel
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Eating more than normal but still feeling hungry
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Blurry or unclear vision
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in the back, thighs, shoulders
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Numb hands
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Drooling while sleeping
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Damp lips at night
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dry lips during the day
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Grind teeth while asleep
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bedwetting
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lethargy; chronic fatigue
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dark circles under eyes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cancer
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive sleep
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Very susceptible to infections
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Swollen glands: tonsils, throat, armpits
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
History of cancer, MS, Parkinson’s arthritis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Loss of appetite
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Soreness on both sides of neck at shoulder
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Feel puffiness in throat
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Look older than chronological age
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Flu-like symptoms often occur
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lupus
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Acne, psoriasis, dermatitis, eczema
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Rapid pulse, heart irregularities
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hay fever
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent cravings for certain foods
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Periods of blurred vision
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Repeated ear trouble
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hyperactivity
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dizzy spells
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Periods of confusion
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Poor concentration
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Epilepsy
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscle cramps or spasms
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Abnormal body odour
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive sweating, night sweats
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bowel disease: IBS, IBD, Crohn’s, etc.
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Joint pains or stiffness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent night urination
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Wheezing
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pale face
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hives
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nose runs constantly
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Noticeable changes in writing throughout day
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nosebleeds
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bloating or gas after eating certain foods
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Canker sores
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Dark circles under eyes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Stuffy nose
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Distinct, lethargic tiredness or sluggishness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cold hands or feet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Mercury amalgams (fillings)
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gain weight easily, fail to lose on diets
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Constipation, less than one bowel movement a day
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Low energy in the morning
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Low pulse rate
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Low body temperature, especially bed rest
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hair dry, brittle, dull, lifeless
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Flaky, dry rough skin
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Feel stiff after sitting still for some time
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Mood swings
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Usually square and wide fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High cholesterol
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Diminished sex drive
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Headaches affecting one side of head
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: loss of menstrual function
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Moody
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Overweight from waist down
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Overweight from waist up
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive urination
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in little finger of left hand
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Swelling in ankles, fingers and/or feet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cold hands or feet
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in left side of upper neck
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Losing weight without trying
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heart races while at rest
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Feel warm/flushed at room temperature
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hands shake or tremble
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Protruding tongue
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heart palpitations
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Nervous behaviour, hyperactivity
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Insomnia
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Increased appetite
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent bowel movements, diarrhea
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Excessive sweating without exercising
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Stress or emotional upsets cause exhaustion
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Blood pressure decreases when going from a lying position to a standing position
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Perspire excessively
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Neck and/or shoulder tension
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Frequent headaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bow lines (depressed furrows) on fingernails
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Occasional cold sweats
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tightness or lump in throat, especially when emotionally disturbed
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
High or low blood pressure
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Rapid pulse
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Short temper
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Puffy face
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain, swelling, stiffness in joints
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Joint inflammation (rheumatoid arthritis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain, stiffness, inflammation of spine
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Facial pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Joints make popping sounds
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gout
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Ankylosing spondylitis
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Bones fracture easily
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Gradual loss of height
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tooth loss; teeth “falling out”
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Lack of exercise
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Rounding of shoulders; stooping
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Female: Menopause
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Pain in forearm or biceps
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Cramps in calf muscle during sleep or exercise
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Painful cramping of feet or toes
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Teeth prone to decay, frequent toothaches
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Malformation of bones
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Insomnia
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscles weak, weak grip, light objects feel heavy
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Heart palpitations
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Diet high in animal foods (meat, dairy, eggs)
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscle pain
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscle weakness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Sprains; muscle strains
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscle(s) spasm
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscles wasting in some part of the body
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Numbness or loss of sensation
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Mood swings and/or depression
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Blurred or double vision
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tingling and/or numbness, especially in extremities
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Muscular stiffness
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Difficulty breathing
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Male: Impotence
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Tremors
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Loss of peripheral vision
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Slurred speech
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Objects fall from hands, reach in wrong place
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Hands tremble
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
Impaired speech
Select one
1 - mild or rarely occurring
2 - for moderate or regularly occurring
3 - severe or often occurring
N/A
