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Symptom Survey
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Symptom Survey
Symptom Survey
Name
Date
Toxic exposure –
Check all that apply
Used pesticides in your home, garden or yard in the last year
Used pesticides in your home, garden or yard in the last year
Details:
Please Explain
Used Round-Up near your home in the last year
Used Round-Up near your home in the last year
Details:
Please Explain
Remodeled any part of your home in the last year
Remodeled any part of your home in the last year
Details:
Please Explain
Exposed to solvents, paint, concrete or other toxins at work or home
Exposed to solvents, paint, concrete or other toxins at work or home
Details:
Please Explain
Fly more than a couple time a year
Fly more than a couple time a year
Details:
Please Explain
Have amalgam/silver fillings
Have amalgam/silver fillings
Details:
Please Explain
Have you ever lived or worked in an environment with mold
Have you ever lived or worked in an environment with mold
Details:
Please Explain
Eat at fast food restaurant more than once per month
Eat at fast food restaurant more than once per month
Details:
Please Explain
Eat non-organic food more than once per week
Eat non-organic food more than once per week
Details:
Please Explain
Live on/ near a farm
Live on/ near a farm
Details:
Please Explain
Exposed to diesel or jet fuel at home or work
Exposed to diesel or jet fuel at home or work
Details:
Please Explain
Wear dry-cleaned clothing
Wear dry-cleaned clothing
Details:
Please Explain
Had amalgam fillings removed
Had amalgam fillings removed
Details:
Please Explain
Head Injury History –
Check all that apply
Have you ever had a concussion, whether or not diagnosed
Have you ever had a concussion, whether or not diagnosed
Details:
Please Explain
Have you ever lost consciousness after an accident or injury
Have you ever lost consciousness after an accident or injury
Details:
Please Explain
Have you ever played contact sports
Have you ever played contact sports
Details:
Please Explain
Have you ever been in a car accident
Have you ever been in a car accident
Details:
Please Explain
Have you ever had whiplash
Have you ever had whiplash
Details:
Please Explain
General Inflammatory load/Immune imbalance: Check box if you’ve had in the last 2 months
Joint pain
Muscle pain
Frequent colds/flus
Exhausted or flare up after exercise
Fatigue
Chronic Malaise (feeling unwell)
Achey all over
Lymph/fluid metabolism Check box if you’ve had in the last 2 months
Swollen hands
Swollen feet
Swollen ankles
Swollen legs
Difficulty breathing lying down
Headache feels like wearing a hat or headband
Cellulite
Swollen joints
Adrenal function: Check box if you’ve had in the last 2 months
Wake up with a start in the middle of the night
Sleep less than 7 hours per night
Sweat without exertion or when nervous
Jumpy/easily startled
Sweaty hands
Sweaty feet
Difficulty keeping eyes open during the day
Overactive/unsettling dreams or nightmares
Sleep less than 7 hours per night
Sleep more than 9 hours per night
Brain inflammation Check box if you’ve had in the last 2 months
Brain fog
Sluggish thinking
Difficulty focusing
Negative outlook
Poor motivation
Easily overwhelmed
Fatigue after mental tasks
Difficulty recalling words
Headache relieved by ice
Confusion
Difficulty remembering tasks
Lack of mental energy
Need caffeine to wake up brain
Fatigued when in pain
Headache at base of skull
Poor reading comprehension
Sensory overload
Cardiovascular system: Check box if you’ve had in the last 2 months
Difficulty falling asleep
Mind runs at night
Palpitations/skipped beat/irregular beats
Heart pounding
Anxiety
Chest pain
Chest pressure
Fatigued during/after exercise
Heavy limbs
Cold fingers
Cold hands
Cold toes
Cold feet
Blood pressure above 130 systolic (upper number)
Blood pressure above 90 diastolic (lower number)
Blood pressure below 120 systolic (upper number)
Blood pressure below 70 diastolic (lower number)
Sores on tip of tongue
Restlessness
Daily coffee consumption
Take ADD meds
Take other stimulants
Take a beta blocker (ends in -ol e.g. Metropolol)
Take any blood pressure medication
Take a statin
Respiratory system: Check box if you’ve had in the last 2 months
Headaches in face or around eyes
Postnasal drip
Snoring
Stuffy nose
Runny nose
Nose bleed
Sneezing
Wheezing
Dry cough
Cough with phlegm
Clogged ears
Sinus pain
Wake up hot at night
Nightsweats
Restless sleep
Shortness of breath/difficulty breathing
Thirsty in middle of night
Dry mouth
Dry nose
Dry skin
Nasal allergies
Sore throat
Smoke cigarettes, marijuana or anything else
Sadness/grief/melancholy
Bags under eyes
Vape anything?
What?
What?
Upper Gastrointestinal system: Check box if you’ve had in the last 2 months
Bleeding gums
Frequent bad breath
Gum disease
Belching
Hiccups
Overfull after eating
Food sits in stomach
Heartburn/acid reflux
Stomach pain
Burning sensation relieved by eating
Difficulty digesting meat
Nausea after eating
Vomiting
Difficulty swallowing
Fatigue after eating
Burning sensation after eating
Take prescription heartburn/GERD medication
Take OTC heartburn medication
Purposefully induced vomiting after eating
Skip meals or restrict food intake
Lower Gastrointestinal system: Check box if you’ve had in the last 2 months
Abdominal bloating
Abdominal gas/flatulence
Foul smelling gas
Lower abdominal pain/cramping
Skipped 1 or more days between bowel movements
More than 3 bowel movements per day.
Hard stool
Difficult to pass stool/takes a long time
Bowel movements feel incomplete
Loose stool (not formed/no real shape)
Urgent bowel movement
Bowel incontinence (cannot hold)
Food reactions (of any kind)
Can only eat a small number of foods
Gurgling guts
Blood in stools
Mucus in stools
Undigested food in stools
Take laxative of any kind
Liver/Gallbladder function: Check box if you’ve had in the last 2 months
Hemorrhoids
Alternating diarrhea and constipation
Acne
Eczema
Air hunger/ feel like you can’t get a deep breath
Bloodshot eyes
Irritability
Easily angered
Fingers turn white/purple when cold
Toes turn white/purple when cold
Unquenchable thirst (doesn’t matter how much you drink)
See floating black spots
Morning sickness
Itchy eyes
Alternating chills/fever
Bitter taste in mouth
Depression
Psoriasis
Skin rashes
Numbness/tingling
One-sided headache
Tension headache
Headache at top of head
Alcohol more than once/week
Irregular menstrual periods (not predictable schedule)
Dry eyes
Sensation of lump stuck in throat
Unable to adapt to stress
Menstrual cycle more than 30 days
Menstrual cycle less than 26 days
Heavy period
Menstrual spotting
Light period
Recreational drugs
What?
What?
Pancreas/Insulin function: Check box if you’ve had in the last 2 months
Fatigue after eating
Sugar cravings after eating
Eat sweets more than 1 x week
Shaky, fatigued or irritable with delayed meals
Difficulty losing weight
Constant thirst
Constant hunger
Frequent, copious urination (large amount)
Energy crash a couple hours after eating
Lack of appetite
Weight increasing
Sudden weight loss/ difficulty maintaining weight
Nausea on empty stomach
Sugar cravings between meals
High A1c/Diabetes
Take any Diabetes medication
What?
What?
Spleen function: Check box if you’ve had in the last 2 months
Bruise easily
Prolapsed organs
Anemia
Thyroid function: Check box if you’ve had in the last 2 months
Take thyroid medication
Feel cold/hard to get warm
Always feel hot when others are cold
History of Hashimotos or Graves disease diagnosis
Excessive hair loss
Puffy face
Easy to gain weight; difficult to lose
Genitourinary function: Check box if you’ve had in the last 2 months
Weak low back
Weak knees
Kidney stones
Bladder infections
Lack of bladder control
Wake during the night 2 or more times to urinate
Frequent urination
Copious urination (very large amount)
Scanty urination (very small amount)
Burning urination
Difficult urination
Strong odor to urine
Dark urine
Reddish urine
Vaginal discharge with unpleasant smell
Erectile dysfunction
Premature ejaculation
Sex hormone function: Check box if you’ve had in the last 2 months
Hot flashes w/ sweating
Hot flashes without sweating
Heat in hands, feet, chest
Low libido
Hair thinning
Uneven urine stream (stops and starts)
Lack of menstrual period/early menopause
Any other symptoms you are concerned about? Please list below
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