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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