Current Symptoms
 

Current Symptoms
Name*  
Address*  
Postal Code*  
Telephone Number*  
Fax Number  
Email Address*  
Current Symptom List
Please number symptom intensity 0 through 10
Weakness*  
Excess body fat*  
Weight*  
Endurance/Fatigue*  
Skin lesions*  
Fingernail abnormalities*  
Scalp or face lesions*  
Recurrent headaches*  
Sore throat*  
Recurrent mouth sores*  
Vision abnormality*  
Visual floaters*  
Dry or Tearing eyes*  
Tinnitus (ringing in ears)*  
Chronic Rhinitis (runny nose)*  
Bloody nasal mucus*  
Chronic/recurrent sinusitis*  
Chronic neck pain*  
Recurrent node swelling*  
Swallowing difficulty*  
Recurrent hoarseness*  
Chronic throat mucus*  
Chronic breast nodes*  
Recurrent nipple discharge*  
Chronic cough*  
Asthma/wheezing*  
Breathlessness*  
Recurrent chest pain*  
Heart rhythm abnormal*  
Fast resting heart rate*  
Gastric reflux*  
Diarrhea*  
Constipation*  
IBS (Both)*  
Chronic nausea*  
Nightime urination (# of times)*  
Slow / Hesitant urine stream*  
Males: Prostatitis  
Males: Low Libido  
Females: Menstrual irregularity  
Females: Pelvic pain/tenderness  
Females: Low Libido  
Females: PMS symptoms  
Joint pain*  
Muscle pain*  
Swelling feet, hands, face*  
Calf cramps*  
Varicose veins*  
Fainting*  
Seizures*  
Any numb or tingling skin*  
Hand tremors*  
Memory problems*  
Coordination problems*  
Frequent mood changes*  
Anxiety*  
Depression*  
Irritability*  
Rage episodes*  
Any other psychiatric diagnosis  


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