|
Digestive Tract
|
|
|
Nausea or Vomiting
|
Diarrhea
|
|
Constipation
|
Bloated feeling
|
|
Belching or passing gas
|
Heartburn
|
|
Total
|
|
|
Ears
|
|
|
Itchy ears
|
Ear aches, ear infections
|
|
Drainage from ears
|
Ringing in ears, hearing loss
|
|
Total
|
|
|
Emotions
|
|
|
Mood swings
|
Anxiety, fear, or nervousness
|
|
Anger, irritability, or aggressiveness
|
Depression
|
|
Total
|
|
|
Energy and Activity
|
|
|
Fatigue, sluggishness
|
Apathy, lethargy
|
|
Hyperactivity
|
Restlessness
|
|
Total
|
|
|
Eyes
|
|
|
Watery or itchy eyes
|
Swollen, reddened or sticky eyelids
|
|
Bags or dark circles under eyes
|
Blurred or tunnel vision
|
|
Total
|
|
|
Head
|
|
|
Headaches
|
Faintness
|
|
Dizziness
|
Insomnia
|
|
Total
|
|
|
Heart
|
|
|
Irregular or skipped heartbeat
|
Rapid or pounding heartbeat
|
|
Chest pain
|
|
|
Total
|
|
|
Joints and Muscles
|
|
|
Pain or aches in joints
|
Arthritis
|
|
Stiffness or limitation of movement
|
Pain or aches in muscles
|
|
Feeling of weakness or tiredness
|
|
|
Total
|
|
|
Lungs
|
|
|
Chest Congestion
|
Asthma, bronchitis
|
|
Shortness of breath
|
Difficulty breathing
|
|
Total
|
|
|
Mind
|
|
|
Poor memory
|
Confusion, poor comprehension
|
|
Difficulty in making decisions
|
Stuttering or stammering
|
|
Slurred speech
|
Learning disabilities
|
|
Total
|
|
|
Mouth / Throat
|
|
|
Chronic coughing
|
Gagging frequently, need to clear throat
|
|
Sore throat, hoarseness, loss of voice
|
Swollen/discolored tongue/gums/lips
|
|
Canker sores
|
|
|
Total
|
|
|
Nose
|
|
|
Stuffy nose
|
Sinus problems
|
|
Hay fever
|
Sneezing attacks
|
|
Excessive mucus formation
|
|
|
Total
|
|
|
Skin
|
|
|
Acne
|
Hives, rashes, or dry skin
|
|
Hair loss
|
Flushing or hot flashes
|
|
Excessive sweating
|
|
|
Total
|
|
|
Weight
|
|
|
Binge eating
|
Crave certain foods
|
|
Excessive weight
|
Compulsive eating
|
|
Water retention
|
Underweight
|
|
Total
|
|
|
Other
|
|
|
Frequent illness
|
Frequent illness
|
|
Genital itch or discharge
|
|
|
Total
|
|
|
Grand Total (Add up all scores)
|
|
