Name: __________________________________Age: ____Sex ...

Chronic yellow or green nasal discharge Yes No (Essential Fatty acid deficiency) Dry eyes? Yes No . Dry mouth? Yes No . LOW THYROID FUNCTIUON. Do you experience fatigue? Yes-4 No-0. Do you have elevated cholesterol? Yes-4 No-0. Do you have difficulty losing weight? Yes-2 No-0. Do you have cold hands and feet? Yes-2 No-0 ................
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