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Current Symptoms
Patient Information
Name*

Address*

Postal Code*

Telephone Number*

Email Address*

Current Symptom List
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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