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Questionnaire

Please fill in the form below.  We will read your form and get back to you within 5 days.  Thank you.

Please fill out the following form to help us understand your physical condition.

Head
Head: Headaches
Head: Faintness
Head: Dizziness
Head: Insomnia
Head: Insomnia
Eyes
Eyes : Watery or Itchy
Eyes : Swollen, red or sticky eyelids
Eyes : Bags or dark circles under eyes
Eyes : Blurred or tunnel vision
Ears
Ears : Itchy Ears
Ears : Earaches, ear infections
Ears : Drainage from ear
Ears : Ringing in ears, hearling loss
Nose
Nose: Stuffy Nose
Nose: Sinus Problems
Nose: Hay fever
Nose: Sneezing atacks
Nose: Excessive mucus formation
Mouth/Throat
Mouth / Throat : Chronic Coughing
Mouth / Throat : Gagging, frequent need to clear throat
Mouth / Throat :Sore throat, hoarseness, loss of voice
Mouth / Throat :Swollen or discoloured tounge, gums, lips
Mouth / Throat : Canker Sores (aphthous ulcers)
Skin
Skin: Acne
Skin: Hives, rashes, dry skin
Skin: Hair Loss
Skin: Flushing, hot flashes
Skin: Excessive Sweating
Heart
Heart: Irregular or skipped heartbeat
Heart: Rapid or pounding heartbeat
Heart: Chest Pain
Lungs
Lungs: Chest Congestion
Lungs: Asthma, bronchitis
Lungs: Shortness of breath
Lungs: Difficulty breathing
Digestion
Digestion: Nausea, vomiting
Digestion: Diarrhea
Digestion: Constipation
Digestion: Bloated feeling
Digestion: Belching, passing gas
Digestion: Heartburn
Digestion: Intestinal / stomach pain
Joints/Muscles
Joints/Muscles: Pain or aches in joints
Joints/Muscles: Stiffness or limitation of movement
Joints/Muscles: Feeling of weakness or tiredness
Weight
Weight: Binge eating / drinking
Weight: Craving certain foods
Weight: Excessive weight
Weight: Compulsive eating
Weight: Water retention
Weight: Underweight
Energy
Energy: Fatigue, sulggishness
Energy: Apathy, Lethargy
Energy: Hyperactivity
Energy: Restlessness
Mind
Mind: Poor memory
Mind: Poor comprehension
Mind: Poor Concentration
Mind: Poor physical coordination
Mind: difficulty in making decisions
Mind: Stuttering or stammering
Mind: Slurred Speach
Mind: Learning disabilities
Emotions
Emotions: Mood swings
Emotions: Anxiety, fear, nervousness
Emotions: Anger, irritability, aggressiveness
Emotions: Depression
Other
Frequent illness
Frequent or urgent urination
Genital itch or discharge
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