Absolute Health Science



Lifestyle and Nutritional Assessment FormDear Client: Please read the instructions of each form carefully and complete this questionnaire with care. Your answers will help me determine the most effective recommendations to make based on your main health concern(s) presented. This health history record is protected and kept strictly confidential. It will not be released without your consent.Name: FORMTEXT ?????Date: FORMTEXT ?????Telephone (Home): FORMTEXT ????? (Work): FORMTEXT ?????(Cell): FORMTEXT ?????Email: FORMTEXT ?????Age: FORMTEXT ?????Sex: M FORMCHECKBOX F FORMCHECKBOX Height: FORMTEXT ?????Weight: FORMTEXT ?????Appointment Reminders? No FORMCHECKBOX Email FORMCHECKBOX Phone FORMCHECKBOX AHS Quarterly Newsletters? Yes FORMCHECKBOX No FORMCHECKBOX Please answer each question carefully and LEAVE BLANK those that don’t apply to you.LIFESTYLE:What is your #1 goal you want to achieve during our time together? FORMTEXT ?????What are your main health concerns? Please list concerns in priority and when they started:1. FORMTEXT ?????4. FORMTEXT ?????2. FORMTEXT ?????5. FORMTEXT ????? 3. FORMTEXT ?????6. FORMTEXT ?????Have you ever experienced any major trauma? FORMTEXT ?????What level of stress do you currently experience? Please quantify on a scale of 1 (low) to 10 (high): FORMTEXT ??What are the major causes of your stress? FORMTEXT ?????How does your stress manifest (show)? FORMTEXT ?????What coping mechanisms do you implement? FORMTEXT ?????Do you vacation regularly? Yes FORMCHECKBOX No FORMCHECKBOX What was your last vacation? FORMTEXT ?????What is your current exercise routine? (Include type, frequency and duration) FORMTEXT ?????Are you satisfied with your present weight? Yes FORMCHECKBOX No FORMCHECKBOX Do you wish to gain weight? FORMCHECKBOX lose weight? FORMCHECKBOX If so, how much? FORMTEXT ?????How would you describe your energy levels on a scale of 1 (low) to 10 (high)? FORMTEXT ??Do you experience any lulls or highs in energy levels throughout the day? Yes FORMCHECKBOX No FORMCHECKBOX If so, what time(s) of day? FORMTEXT ?????How many hours on average do you sleep daily? FORMTEXT ?????Do you: have difficulty falling asleep? FORMCHECKBOX Staying asleep? FORMCHECKBOX Awaken feeling unrested? FORMCHECKBOX Snore? FORMCHECKBOX What is your occupation? FORMTEXT ?????What do you enjoy/not enjoy about work? FORMTEXT ?????How many hours each week do you work? FORMTEXT ?????Do you work shifts? FORMCHECKBOX Regular schedule? FORMCHECKBOX Do you smoke? Yes FORMCHECKBOX No FORMCHECKBOX If yes, how much and for how long? FORMTEXT ????? How do you feel about smoking? FORMTEXT ?????Are you ever exposed to smoke at home or at work? Yes FORMCHECKBOX No FORMCHECKBOX Do you use recreational drugs? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please describe: FORMTEXT ?????Have you ever been treated for: drug dependency? FORMCHECKBOX Alcohol dependency? FORMCHECKBOX How many hours do you spend daily, on average: Driving? FORMTEXT ?????Watching TV? FORMTEXT ?????Reading? FORMTEXT ?????On a computer? FORMTEXT ?????Sitting at a desk? FORMTEXT ?????What is your current morning routine? FORMTEXT ????? Evening routine? FORMTEXT ?????What are your interests and hobbies? Please list: FORMTEXT ?????How much free time do you feel you have in a day? FORMTEXT ?????If need be, how would you make more time for yourself? FORMTEXT ?????Do you regularly check in with yourself (self-reflect)? Yes FORMCHECKBOX No FORMCHECKBOX Need reminders to do so FORMCHECKBOX Time permitting, what would you like to incorporate into your day? FORMTEXT ?????MEDICAL HISTORY:Are you currently taking medication (including birth control)? Yes FORMCHECKBOX No FORMCHECKBOX Name of Prescription MedicationReason(s) for MedicationDuration of Medication FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Have you taken antibiotics over the past 5 years? Yes FORMCHECKBOX No FORMCHECKBOX If yes, when were they last taken and the reason for taking it? FORMTEXT ?????Are you currently taking Natural Health Products (NHPs)? (Includes vitamins, minerals, herbs and homeopathic remedies) Yes FORMCHECKBOX No FORMCHECKBOX Name of NHPReason(s) for NHPDaily Amount/Dose FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Do you have any allergies or sensitivities (including to medication)? Yes FORMCHECKBOX No FORMCHECKBOX If so, please list: FORMTEXT ?????Are you anaphylactic (life-threatening allergy)? If so, to what: FORMTEXT ?????Do you have any silver-mercury fillings? Yes FORMCHECKBOX No FORMCHECKBOX If so, how many and for how long? FORMTEXT ?????Do you have any root canals? Yes FORMCHECKBOX No FORMCHECKBOX If so, how many and for how long? FORMTEXT ?????Have you ever been:a) Diagnosed with an illness? Yes FORMCHECKBOX No FORMCHECKBOX If so, please explain: FORMTEXT ?????b) Hospitalized? Yes FORMCHECKBOX No FORMCHECKBOX If so, for what reason: FORMTEXT ?????Have you had surgery to remove your gall bladder? FORMCHECKBOX Tonsils? FORMCHECKBOX Appendix? FORMCHECKBOX If so, explain: FORMTEXT ?????Have you experienced fungal infections (Ex. Jock itch, Athlete’s foot)? Yes FORMCHECKBOX No FORMCHECKBOX If so, please describe: FORMTEXT ?????Have you experienced a decline in sexual interest? Yes FORMCHECKBOX No FORMCHECKBOX Have you had kidney stones or gallstones? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please describe: FORMTEXT ?????How often do you have a bowel movement daily? FORMTEXT ?????Do you strain to have a bowel movement? Yes FORMCHECKBOX No FORMCHECKBOX Occasionally FORMCHECKBOX Related to particular food or circumstance? FORMTEXT ?????Do you have loose bowel movements? Yes FORMCHECKBOX No FORMCHECKBOX Occasionally FORMCHECKBOX Related to particular food or circumstance? FORMTEXT ?????Is there undigested food in your stools? Yes FORMCHECKBOX No FORMCHECKBOX Occasionally FORMCHECKBOX Other bowel-related concerns? (Colour, blood, oily, etc.) FORMTEXT ?????FAMILY HISTORY: Use “F” for father, “M” for mother, “S” for sibling, “G” for grandparent, “O” for other(s): FORMTEXT ?????Allergies FORMTEXT ?????Diabetes FORMTEXT ?????Intestinal Disease FORMTEXT ?????Alcoholism FORMTEXT ?????Drug Abuse FORMTEXT ?????Kidney Dysfunction FORMTEXT ?????Arthritis FORMTEXT ?????Gall Bladder Issues FORMTEXT ?????Mental Illness FORMTEXT ?????Asthma FORMTEXT ?????High Cholesterol FORMTEXT ?????Osteoporosis FORMTEXT ?????Autoimmune Disease FORMTEXT ?????Heart Disease FORMTEXT ?????Skin Conditions FORMTEXT ?????Cancer FORMTEXT ?????Hypertension FORMTEXT ?????UlcersType(s) of Cancer: FORMTEXT ?????Other condition(s): FORMTEXT ?????FEMALES:Are you pregnant? Yes FORMCHECKBOX No FORMCHECKBOX Are you currently breastfeeding? Yes FORMCHECKBOX No FORMCHECKBOX Have you noticed any changes in menses? (Ex. Frequency, duration, flow, clotting, etc.) Yes FORMCHECKBOX No FORMCHECKBOX If so, please specify: FORMTEXT ?????Do you suffer from PMS symptoms? Please specify: FORMTEXT ?????Are you pre-menopausal? Yes FORMCHECKBOX No FORMCHECKBOX Post-menopausal? Yes FORMCHECKBOX No FORMCHECKBOX Are you experiencing any menopausal symptoms? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please specify: FORMTEXT ?????Have you had a bone density test? Yes FORMCHECKBOX No FORMCHECKBOX If yes, what was the result? FORMTEXT ?????MALES:Have you experienced any prostate problems? (Ex. frequent urination, discomfort during urination) Yes FORMCHECKBOX No FORMCHECKBOX If yes, please describe: FORMTEXT ?????NUTRITIONAL AND DIETARY HABITS:How many times a day do you eat, on average? Main meals: FORMTEXT ??? Times of day: FORMTEXT ?????Snacks: FORMTEXT ??? Times of day: FORMTEXT ?????Provide examples of your typical meals and snacks:Breakfast: FORMTEXT ?????Lunch: FORMTEXT ?????Dinner: FORMTEXT ?????Snacks: FORMTEXT ?????Do you eat: With family? FORMCHECKBOX Home alone? FORMCHECKBOX On the run? FORMCHECKBOX Restaurant? FORMCHECKBOX Fast food? FORMCHECKBOX Where do you commonly grocery shop? FORMTEXT ?????What percentage of meals/snacks consumed are homemade? FORMTEXT ?????In terms of preparing your own meals, what is your skill level in the kitchen? Please quantify on a scale of 1 (low) to 10 (high): FORMTEXT ??How many servings of each food type do you typically consume in a day? FORMTEXT ????? FruitFresh FORMCHECKBOX Frozen FORMCHECKBOX Canned FORMCHECKBOX Dried FORMCHECKBOX FORMTEXT ????? VegetablesCooked FORMCHECKBOX Raw FORMCHECKBOX Frozen FORMCHECKBOX Canned FORMCHECKBOX FORMTEXT ????? Whole GrainsType: FORMTEXT ????? FORMTEXT ????? ProteinType: FORMTEXT ????? FORMTEXT ????? DairyType: FORMTEXT ????? FORMTEXT ????? FatsType: FORMTEXT ????? FORMTEXT ????? OtherType(s): FORMTEXT ?????Do you eat or use (indicate “1” for “rarely”, “2” for “regularly”, “3” for “often”): FORMTEXT ????? Aluminum pans FORMTEXT ????? Artificial Sweeteners FORMTEXT ????? Candy FORMTEXT ????? Cigarettes FORMTEXT ????? Refined Foods (pastries, white pasta, etc.) FORMTEXT ????? Fried Foods FORMTEXT ????? Luncheon Meats FORMTEXT ????? Margarine FORMTEXT ????? Microwave FORMTEXT ????? Fast FoodsPlease indicate how many cups of the following you drink per day: FORMTEXT ????? Tap water FORMTEXT ????? Coffee FORMTEXT ????? Tea FORMTEXT ????? Soft drinks (diet) FORMTEXT ????? Soft drinks (regular) FORMTEXT ????? Fresh fruit juices FORMTEXT ????? Fruit juices (prepared) FORMTEXT ????? Milk FORMTEXT ????? Prepared vegetable juices FORMTEXT ????? Fresh vegetable juices FORMTEXT ????? Red wine FORMTEXT ????? White wine FORMTEXT ????? Beer FORMTEXT ????? Other alcoholic beverages FORMTEXT ????? Bottled or spring water FORMTEXT ????? Herbal tea FORMTEXT ????? Other: FORMTEXT ?????Do you currently follow a special diet? Yes FORMCHECKBOX No FORMCHECKBOX If yes, please explain: FORMTEXT ?????Do you avoid certain foods? Yes FORMCHECKBOX No FORMCHECKBOX If yes, list food(s) and reason why: FORMTEXT ?????How often do you eat meat? Daily FORMCHECKBOX 3-5/week FORMCHECKBOX Once/week or less FORMCHECKBOX How often do you consume dairy? Daily FORMCHECKBOX 3-5/week FORMCHECKBOX Once/week or less FORMCHECKBOX What’s your favourite food(s) and how often do you eat them? FORMTEXT ?????Which food(s) do you crave, and how often do you eat them? FORMTEXT ?????Do you experience any symptoms of meals are missed? Yes FORMCHECKBOX No FORMCHECKBOX Please explain: FORMTEXT ?????Do you experience any symptoms after meals? Yes FORMCHECKBOX No FORMCHECKBOX Please explain: FORMTEXT ?????COMMENTS: FORMTEXT ?????Nutri-System Profile (NSP) Assessment FormPlease indicate if you’re experiencing any of the symptoms or activities below by indicating: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.General fatigue or weakness FORMTEXT ???Varicose veins FORMTEXT ???Difficulty losing weight FORMTEXT ???Feeling out of control FORMTEXT ???Frequent illness/infections FORMTEXT ???Food/chemical sensitivities FORMTEXT ???High stress lifestyle FORMTEXT ???Frequent yeast/fungus problems FORMTEXT ???Smoking FORMTEXT ???Bones break easily, osteoporosis FORMTEXT ???Drink more than 2 cups of coffee/day FORMTEXT ???Too little exercise FORMTEXT ???Bad breathe and/or body odour FORMTEXT ???Excessive mucous FORMTEXT ???Constipation FORMTEXT ???Shortness of breath climbing stairs FORMTEXT ???Bags under eyes FORMTEXT ???Tingling in lips, fingers, arms, legs FORMTEXT ???Craves sugar, bread, alcohol FORMTEXT ???Chest pains FORMTEXT ???Difficulty digesting certain foods FORMTEXT ???Very rapid or slow heart beat FORMTEXT ???Recent antibiotic use FORMTEXT ???Painful, hard or thin bowel movements FORMTEXT ???Allergies FORMTEXT ???Alternating constipation/diarrhea FORMTEXT ???Poor concentration or memory FORMTEXT ???Recurrent bladder infections FORMTEXT ???Belching or burping after meals FORMTEXT ???Female: Menopause, hot flashes FORMTEXT ???Skin/complexion problems FORMTEXT ???Female: PMS FORMTEXT ???Frequent consumption of red meat FORMTEXT ???Difficult urination FORMTEXT ???Regular use of dairy products FORMTEXT ???Swollen glands, puffy throat FORMTEXT ???Heavy alcohol consumption FORMTEXT ???Lower abdominal pain FORMTEXT ???Exposure to toxins/chemicals FORMTEXT ???Frequent need to urinate FORMTEXT ???Frequent mood swings FORMTEXT ???Joint pain FORMTEXT ???Depressed and/or irritable FORMTEXT ???Sinus inflammation/discharge FORMTEXT ???Brittle fingernails FORMTEXT ???Arthritis FORMTEXT ???Dry, brittle hair, split ends FORMTEXT ???Sudden weight gain/loss FORMTEXT ???High fat/high cholesterol diet FORMTEXT ???Headache/Migraines FORMTEXT ???Nervousness/anxiety/tension/worry FORMTEXT ???Female: Taking birth control pills FORMTEXT ???Insomnia, restless sleep FORMTEXT ???Lower back pains FORMTEXT ???Low fiber diet FORMTEXT ???Dry, flaky skin FORMTEXT ???Muscle cramps FORMTEXT ???Drink less than 6 glasses of fluid/day FORMTEXT ???Sleepy when sitting up FORMTEXT ???Water retention FORMTEXT ???Female: menstrual cramps FORMTEXT ???Low sex drive FORMTEXT ???Bronchitis/asthma//pneumonia/emphysema FORMTEXT ???Feeling heavy/bloated after meals FORMTEXT ???Cellulite FORMTEXT ???Chronic cough FORMTEXT ???Cold hands and feet FORMTEXT ???COMMENTS: FORMTEXT ?????PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.THE DIGESTIVE SYSTEMExcessive gas, belching or burping after meals FORMTEXT ???Full feeling after heavy meat meal FORMTEXT ???Stomach bloated after eating FORMTEXT ???Heavy, tired feeling after eating FORMTEXT ???Sleepy after eating FORMTEXT ???Nausea after taking supplements FORMTEXT ???Longitudinal striations on fingernails FORMTEXT ???Acne FORMTEXT ???Eat when rushed/in a hurry FORMTEXT ???Undigested food in the stool FORMTEXT ???Bad breathe FORMTEXT ???Stomach pain 1 hour after eating or at night FORMTEXT ???Sensation of acidity in abdominal area FORMTEXT ???Burning sensation in stomach FORMTEXT ???Heartburn, indigestion FORMTEXT ???Pain aggravated by worry/tension FORMTEXT ???Blood in stool FORMTEXT ???Hiatal hernia FORMTEXT ???Lower back pain FORMTEXT ???Gastritis, gastric ulcer FORMTEXT ???Long term aspirin use FORMTEXT ???Nausea, vomiting FORMTEXT ???Yellow or pale fingernails FORMTEXT ???Food allergies FORMTEXT ???Skin oily on nose and forehead FORMTEXT ???Irritable, easily angered FORMTEXT ???Fats/greasy foods cause nausea, headaches FORMTEXT ???Weight gain around the abdomen FORMTEXT ???Vertical white streaks on fingernails FORMTEXT ???Yellow palms FORMTEXT ???Onions, cabbage, radishes, cucumbers cause bloating/gas FORMTEXT ???Jaundice FORMTEXT ???Bad breathe; bad taste in mouth FORMTEXT ???Poor concentration FORMTEXT ???Excess body odour FORMTEXT ???Difficulty losing weight FORMTEXT ???High cholesterol/high cholesterol diet FORMTEXT ???Acne, boils, rashes, psoriasis or eczema FORMTEXT ???Migraine headaches FORMTEXT ???Constipation FORMTEXT ???Discomfort underneath right ribcage FORMTEXT ???Gall stones; history of gallstones FORMTEXT ???High cholesterol diet; high blood cholesterol levels FORMTEXT ???Stool appears clay-coloured, foul odoured FORMTEXT ???Severe pain in right upper abdomen FORMTEXT ???Constipation FORMTEXT ???Severe abdominal pain FORMTEXT ???Fever FORMTEXT ???Nausea and vomiting FORMTEXT ???Alcohol addiction FORMTEXT ???Slow digestion; feel full for hours after eating FORMTEXT ???Jaundice FORMTEXT ???Hungry up to 3 hours after eating FORMTEXT ???Family history of diabetes FORMTEXT ???Strong cravings for sweets, starches, coffee or alcohol FORMTEXT ???Fatigue FORMTEXT ???Nervous/anxious feelings relieved by eating FORMTEXT ???Frequent headaches FORMTEXT ???Irritable if late for or skip a meal FORMTEXT ???Fainting spells FORMTEXT ???Overweight FORMTEXT ???Depression FORMTEXT ???Addicted to pop and/or coffee with sugar FORMTEXT ???Lose temper easily FORMTEXT ???Frequent “midnight snacks” FORMTEXT ???PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.THE INTESTINAL SYSTEMExtreme fatigue FORMTEXT ???Rectal itching FORMTEXT ???Recurrent vaginal infections FORMTEXT ???Abnormal muscle aches from exercise FORMTEXT ???Frequent use of antibiotics FORMTEXT ???Excessive wax in ears FORMTEXT ???White coated tongue, oral thrush FORMTEXT ???Unexpected/unexplained weight gain FORMTEXT ???Craves sugars, bread, alcohol FORMTEXT ???Impotence FORMTEXT ???Headaches FORMTEXT ???Canker sores FORMTEXT ???Tonsillitis, recurrent strep throat FORMTEXT ???Athlete’s foot, finger/toenail fungus, ringworm FORMTEXT ???Itchy, watery or dry eyes FORMTEXT ???Jock itch FORMTEXT ???Skin flushes FORMTEXT ???“Brain fog” FORMTEXT ???Chronic indigestion, frequently use antacids FORMTEXT ???Irritability FORMTEXT ???Always cold, especially in extremities FORMTEXT ???Memory loss FORMTEXT ???Female: PMS FORMTEXT ???Mental confusion FORMTEXT ???Pain in pelvic area FORMTEXT ???Depression or anger for no reason FORMTEXT ???Abdominal gas and bloating FORMTEXT ???Anxiety/panic attacks FORMTEXT ???Loss of sex drive FORMTEXT ???Inability to concentrate FORMTEXT ???Cystitis, repeated bladder infection FORMTEXT ???Phobic/compulsive FORMTEXT ???Increasing food and chemical sensitivities FORMTEXT ???Lethargy FORMTEXT ???Female: Endometriosis/ ovary problems FORMTEXT ???Mood swings FORMTEXT ???Chronic diarrhea FORMTEXT ???Itchy ears, nose, anus FORMTEXT ???Hives, psoriasis, acne, skin rashes FORMTEXT ???Forgetfulness FORMTEXT ???Pain in the back, thighs, shoulders FORMTEXT ???Slow reflexes FORMTEXT ???Numb hands FORMTEXT ???Gas and bloating FORMTEXT ???Drooling while sleeping FORMTEXT ???Unclear thinking FORMTEXT ???Damp lips at night FORMTEXT ???Loss of appetite FORMTEXT ???Dry lips during the day FORMTEXT ???Yellowish or pale face FORMTEXT ???Grind teeth while asleep FORMTEXT ???Fast heartbeat FORMTEXT ???Bedwetting FORMTEXT ???Heart pin FORMTEXT ???Lethargy; chronic fatigue FORMTEXT ???Pain in navel FORMTEXT ???Dark circles under eyes FORMTEXT ???Eating more than normal but still feeling hungry FORMTEXT ???Cancer FORMTEXT ???Blurry or unclear vision FORMTEXT ???Rectal itching FORMTEXT ???THE LYMPHATIC SYSTEMExcessive sleep FORMTEXT ???Soreness on both sides of neck at shoulder FORMTEXT ???Very susceptible to infections FORMTEXT ???Feel puffiness in throat FORMTEXT ???Swollen glands: tonsils, throat, armpits FORMTEXT ???Look older than chronological age FORMTEXT ???History of cancer, MS, Parkinson’s, arthritis FORMTEXT ???Flu-like symptoms often occur FORMTEXT ???Loss of appetite FORMTEXT ???Lupus FORMTEXT ???Headaches FORMTEXT ???PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.Acne, psoriasis, dermatitis, eczema FORMTEXT ???Excessive sweating, night sweats FORMTEXT ???Rapid pulse, heart irregularities FORMTEXT ???Bowel disease: IBS, IBD, Crohn’s, etc. FORMTEXT ???Frequent headaches FORMTEXT ???Joint pains or stiffness FORMTEXT ???Hay fever FORMTEXT ???Frequent night urination FORMTEXT ???Frequent cravings for certain foods FORMTEXT ???Wheezing FORMTEXT ???Periods of blurred vision FORMTEXT ???Pale face FORMTEXT ???Repeated ear trouble FORMTEXT ???Hives FORMTEXT ???Hyperactivity FORMTEXT ???Nose runs constantly FORMTEXT ???Dizzy spells FORMTEXT ???Noticeable changes in writing throughout day FORMTEXT ???Periods of confusion FORMTEXT ???Nosebleeds FORMTEXT ???Poor concentration FORMTEXT ???Bloating or gas after eating certain foods FORMTEXT ???Epilepsy FORMTEXT ???Canker sores FORMTEXT ???Muscle cramps or spasms FORMTEXT ???Dark circles under eyes FORMTEXT ???Abnormal body odour FORMTEXT ???Stuffy nose FORMTEXT ???THE ENDOCRINE SYSTEMDistinct, lethargic tiredness or sluggishness FORMTEXT ???Hair dry, brittle, dull, lifeless FORMTEXT ???Cold hands or feet FORMTEXT ???Flaky, dry rough skin FORMTEXT ???Mercury amalgams (fillings) FORMTEXT ???Feel stiff after sitting still for some time FORMTEXT ???Gain weight easily, fail to lose on diets FORMTEXT ???Mood swings FORMTEXT ???Constipation, less than one bowel movement a day FORMTEXT ???Usually square and wide fingernails FORMTEXT ???Low energy in the morning FORMTEXT ???High cholesterol FORMTEXT ???Low pulse rate FORMTEXT ???Low sex drive FORMTEXT ???Low body temperature, especially bed rest FORMTEXT ???Losing weight without trying FORMTEXT ???Insomnia FORMTEXT ???Heart races while at rest FORMTEXT ???Increased appetite FORMTEXT ???Feel warm/flushed at room temperature FORMTEXT ???Frequent bowel movements, diarrhea FORMTEXT ???Hands shake or tremble FORMTEXT ???Excessive sweating without exercising FORMTEXT ???Protruding tongue FORMTEXT ???Nervous behavior, hyperactivity FORMTEXT ???Heart palpitations FORMTEXT ??? FORMTEXT ???Headaches affecting one side of head FORMTEXT ???Excessive urination FORMTEXT ???Female: Loss of menstrual function FORMTEXT ???Pain in little finger of left hand FORMTEXT ???Moody FORMTEXT ???Swelling in ankles, fingers and/or feet FORMTEXT ???Overweight from waist up FORMTEXT ???Cold hands or feet FORMTEXT ???Overweight from waist down FORMTEXT ???Pain in left side of upper neck FORMTEXT ???Stress or emotional upset cause exhaustion FORMTEXT ???Occasional cold sweats FORMTEXT ???Dizzy/light-headed upon standing quickly from a lying or crouched position FORMTEXT ???Tightness or lump in throat, especially when emotionally disturbed FORMTEXT ???Sweat excessively FORMTEXT ???High or low blood pressure FORMTEXT ???Neck and/or shoulder tension/pain FORMTEXT ???Rapid pulse FORMTEXT ???Frequent headaches FORMTEXT ???Short temper FORMTEXT ???Bow lines (depressed furrows) on fingernails FORMTEXT ???Puffy face FORMTEXT ???PLEASE COMPLETE THE FOLLOWING SUB-QUESTIONNAIRES USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.Forgetfulness, “brain fog” FORMTEXT ???Low resistance to infections, catch cold/flu easily FORMTEXT ???Energy crash mid-afternoon (around 2-5pm) FORMTEXT ???Difficulty falling or staying asleep FORMTEXT ???Need to snack to help energy levels and cravings FORMTEXT ???Increased muscle soreness with similar physical activity level FORMTEXT ???Abdominal weight gain FORMTEXT ???Female: Worsened PMS symptoms during menstrual cycle FORMTEXT ???Low sex drive or lack of interest FORMTEXT ???Frequently wake up around 2-4pm, can’t fall back asleep FORMTEXT ???Anxiety, irritability, depression (mood swings) FORMTEXT ???Low stamina, energy and difficulty maintaining muscle mass FORMTEXT ???Decreased ability to deal with stress and deadlines FORMTEXT ???Low tolerance towards alcohol or caffeine FORMTEXT ???Strong carbohydrate or salt cravings FORMTEXT ???Cold hands or feet/other extremities FORMTEXT ???Hair loss FORMTEXT ???Dry skin FORMTEXT ???Significant improvements in stress levels during vacation or time away from work? FORMTEXT ???THE STRUCTURAL-MUSCULAR/SKELETAL SYSTEMPain, swelling, stiffness in joints FORMTEXT ???Rounding of shoulders, stooping FORMTEXT ???Joint inflammation (rheumatoid arthritis) FORMTEXT ???Female: Menopause FORMTEXT ???Pain, stiffness, inflammation of spine FORMTEXT ???Pain in forearm or biceps FORMTEXT ???Facial pain FORMTEXT ???Cramps in calf muscle during sleep or exercise FORMTEXT ???Joints making popping sounds FORMTEXT ???Painful cramping in feet or toes FORMTEXT ???Gout FORMTEXT ???Teeth prone to decay; frequent toothaches FORMTEXT ???Ankylosing spondylitis FORMTEXT ???Malformation of bones FORMTEXT ???Bones fracture easily FORMTEXT ???Insomnia FORMTEXT ???Gradual loss of height FORMTEXT ???Muscles weak, weak grip, light objects feel heavy FORMTEXT ???Tooth loss; teeth “falling out” FORMTEXT ???Heart palpitations FORMTEXT ???Lack of exercise FORMTEXT ???Diet high in animal foods (meat, dairy, eggs) FORMTEXT ???Muscle pain FORMTEXT ???Sprains; muscle strains FORMTEXT ???Muscle weakness FORMTEXT ???Muscle(s) spasm FORMTEXT ???Muscle wasting in some part of the body FORMTEXT ???Tremors FORMTEXT ???Numbness or loss of sensation FORMTEXT ???Loss of peripheral vision FORMTEXT ???Mood swings and/or depression FORMTEXT ???Slurred speech FORMTEXT ???Blurred or double vision FORMTEXT ???Objects fall from hand, reach in wrong place FORMTEXT ???Tingling and/or numbness, especially in extremities FORMTEXT ???Hands tremble FORMTEXT ???Muscular stiffness FORMTEXT ???Impaired speech FORMTEXT ???Male: Impotence FORMTEXT ???Difficulty breathing FORMTEXT ???COMMENTS: FORMTEXT ?????Nutrient Deficiency TestPLEASE COMPLETE THE FOLLOWING TEST USING THE SAME RATING SYSTEM: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring or LEAVE BLANK if the symptom/statement does not apply.Excess fluid retention (edema) FORMTEXT ?????Nausea or dizziness FORMTEXT ?????Poor coordination FORMTEXT ?????General, overall weakness FORMTEXT ?????Anemia FORMTEXT ?????Cataracts FORMTEXT ?????Catch colds, flu, infections easily FORMTEXT ?????Cuticles tear easily FORMTEXT ?????Hair dull, dry, sparse, loose and falling FORMTEXT ?????Rough, dry or scaly skin FORMTEXT ?????Dry, brittle hair FORMTEXT ?????Eczema FORMTEXT ?????Psoriasis FORMTEXT ?????Poor memory FORMTEXT ?????Irregular menstrual periods FORMTEXT ?????Osteoporosis FORMTEXT ?????Bones break easily FORMTEXT ?????Irregular heart beat FORMTEXT ?????Brittle nails FORMTEXT ?????Muscle cramps FORMTEXT ?????Crowded teeth FORMTEXT ?????Insomnia FORMTEXT ?????High blood cholesterol FORMTEXT ?????Intolerance to alcohol FORMTEXT ?????Diabetic or hypoglycemia FORMTEXT ?????Overweight FORMTEXT ?????Sugar cravings FORMTEXT ?????Chronic dieter FORMTEXT ?????Kidney disease FORMTEXT ?????Fatigue, extreme lack of energy FORMTEXT ?????Dry hair FORMTEXT ?????Thyroid problems; goiter FORMTEXT ?????Overweight FORMTEXT ?????Constipation FORMTEXT ?????Cold hands or feet FORMTEXT ?????Brittle nails FORMTEXT ?????Lack of energy or strength FORMTEXT ?????Dizziness FORMTEXT ?????Cravings for ice FORMTEXT ?????Pale lower eyelid FORMTEXT ?????Tachycardia FORMTEXT ?????Spoon shaped nails FORMTEXT ?????Muscle spasms or tremors FORMTEXT ?????Gall stones FORMTEXT ?????Cravings for chocolate FORMTEXT ?????Irregular heartbeat FORMTEXT ?????Excessive body odour FORMTEXT ?????Joint pains FORMTEXT ?????Bursitis, tendonitis FORMTEXT ?????Prone to injuries FORMTEXT ?????Weak knees FORMTEXT ?????Creaking or clicking of joints FORMTEXT ?????Weak muscles FORMTEXT ?????High blood pressure FORMTEXT ?????Swelling of ankles FORMTEXT ?????Always thirsty FORMTEXT ?????Irregular heartbeat FORMTEXT ?????Muscular weakness and fatigue FORMTEXT ?????Dry hair FORMTEXT ?????Thin hair FORMTEXT ?????Weak immunity; frequent infection FORMTEXT ?????Dandruff FORMTEXT ?????Cataracts FORMTEXT ?????White spots on fingernails FORMTEXT ?????Acne FORMTEXT ?????Male: Poor sperm production FORMTEXT ?????Frequent infection FORMTEXT ?????Poor dream recall FORMTEXT ?????Cuts/wounds heal slowly FORMTEXT ?????Loss of sense of smell or taste FORMTEXT ?????Thinning hair FORMTEXT ?????Red stretch marks FORMTEXT ?????Hard little bumps around elbows FORMTEXT ?????Dry or rough skin FORMTEXT ?????Dry hair, acne FORMTEXT ?????Poor night vision; night blindness FORMTEXT ?????Susceptibility to respiratory infections FORMTEXT ?????Slow light to dark adaptation FORMTEXT ?????Eyes unable to produce tears FORMTEXT ?????Weak tooth enamel FORMTEXT ?????Dandruff FORMTEXT ?????Fatigue FORMTEXT ?????Apathy, depression FORMTEXT ?????Loss of knee jerk response FORMTEXT ?????Irregular heartbeat FORMTEXT ?????GI disorders FORMTEXT ?????Dry skin around nose and lips FORMTEXT ?????Cracks/sores in corner of mouth FORMTEXT ?????Bloodshot or itchy eyes FORMTEXT ?????Cataracts FORMTEXT ?????Eyes sensitive to light FORMTEXT ?????Abnormal hair loss FORMTEXT ?????Trembling painful and purplish-red tongue FORMTEXT ?????Sore tongue FORMTEXT ?????Fatigue FORMTEXT ?????Loss of appetite FORMTEXT ?????Skin disorders FORMTEXT ?????Swelling of mouth FORMTEXT ?????Smooth tongue FORMTEXT ?????Mental confusion FORMTEXT ?????Loss of sense of humour FORMTEXT ?????Canker sores in mouth FORMTEXT ?????Anemia FORMTEXT ?????Irritability or nervousness FORMTEXT ?????Insomnia, poor dream recall FORMTEXT ?????Sore thumbs, kidney stones FORMTEXT ?????Female: acne worse during menstruation FORMTEXT ?????Female: morning sickness during pregnancy FORMTEXT ?????Fatigue and weakness FORMTEXT ?????Lightheadedness or dizziness FORMTEXT ?????Heart palpitations FORMTEXT ?????Shortness of breath; chest pain FORMTEXT ?????Sore, red, glazed-looking tongue FORMTEXT ?????Irritability; inability to concentrate FORMTEXT ?????Ringing in ears (tinnitus) FORMTEXT ?????Nausea and diarrhea FORMTEXT ?????Memory loss, forgetfulness FORMTEXT ?????Poor coordination FORMTEXT ?????Skin disorders FORMTEXT ?????Smooth and pale tongue FORMTEXT ?????Loss of appetite FORMTEXT ?????Pale fingernails FORMTEXT ?????Irregular heartbeat FORMTEXT ?????Severe depression FORMTEXT ?????Mild anemia FORMTEXT ?????Hair loss FORMTEXT ?????High blood pressure FORMTEXT ?????High blood cholesterol FORMTEXT ?????Overweight FORMTEXT ?????Eczema FORMTEXT ?????Bleeding ulcer FORMTEXT ?????Disoriented, memory loss FORMTEXT ?????Difficulty losing weight FORMTEXT ?????Paleness FORMTEXT ?????Sore red tongue FORMTEXT ?????Bleeding gums FORMTEXT ?????Diarrhea FORMTEXT ?????Insomnia FORMTEXT ?????Irritability FORMTEXT ?????Fatigue FORMTEXT ?????Constipation FORMTEXT ?????General gastrointestinal disorders FORMTEXT ?????Premature greying FORMTEXT ?????Depression and irritability FORMTEXT ?????Fatigue FORMTEXT ?????Headache FORMTEXT ?????Abdominal pain FORMTEXT ?????Anorexia FORMTEXT ?????Nausea FORMTEXT ?????Burning feet FORMTEXT ?????Depression and irritability FORMTEXT ?????Headache FORMTEXT ?????Nervousness FORMTEXT ?????Purplish red tongue FORMTEXT ?????Bleeding gums FORMTEXT ?????Urinary tract infections FORMTEXT ?????Abnormal nose bleeds FORMTEXT ?????Slow healing of wounds FORMTEXT ?????General weakness FORMTEXT ?????Shortness of breath FORMTEXT ?????Skin bruises easily FORMTEXT ?????Ruptured blood vessels in eyes FORMTEXT ?????Excessive hair loss FORMTEXT ?????Aching bones and joints FORMTEXT ?????Muscle weakness FORMTEXT ?????Pain in ribs, spine, legs FORMTEXT ?????Malformation of bones FORMTEXT ?????Osteomalacia FORMTEXT ?????Osteoporosis FORMTEXT ?????Muscle cramps FORMTEXT ?????Rickets, insomnia FORMTEXT ?????Nearsightedness (myopia) FORMTEXT ?????Heart disease FORMTEXT ?????Premature aging FORMTEXT ?????Weakness FORMTEXT ?????Irritability FORMTEXT ?????Diarrhea FORMTEXT ?????Poor skin condition FORMTEXT ?????Brittle hair FORMTEXT ?????Muscle wasting FORMTEXT ?????COMMENTS: FORMTEXT ????? ................
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