| 1. Do you have abdominal pain? | No Yes |
| 2. Do you have alcohol intolerance? |
No
Yes
|
| 3. Do you have allergies? Are you sensitive to medicines, inhalants, odors, and foods? |
No
Yes
|
| 4. Do you have altered taste, smell, hearing? |
No
Yes
|
| 5. Do you experience anxiety/panic attacks or seizures? |
No
Yes
|
| 6. Do you experience aphasia (inability to find the right word, saying the wrong word) and/or dyscalculia (difficulty with numbers)? |
No
Yes
|
| 7. Do you have a balance disturbance? |
No
Yes
|
| 8. Do you have a bitter or metallic taste in your mouth? |
No
Yes
|
| 9. Do you have bladder/prostate problems, frequent urination? Do you experience burning during urination? Do you experience incontinence? |
No
Yes
|
| 10. Do you experience bloating after meals? |
No
Yes
|
| 11. Do you have blurred vision, are your eyes scratchy? |
No
Yes
|
| 12. Do you have bouts of diarrhea or constipation? |
No
Yes
|
| 13. Do you bruise easily? |
No
Yes
|
| 14. Is your thyroid inflamed? |
No
Yes
|
| 15. Do you have a white coated tongue? |
No
Yes
|
| 16. Do you have carpal tunnel syndrome? |
No
Yes
|
| 17. Do you have chemical sensitivities? |
No
Yes
|
| 18. Do you have chest pain or even serious cardiac rhythm disturbances? |
No
Yes
|
| 19. Are you cold most of the time? |
No
Yes
|
| 20. Do you have a chronic sore throat? |
No
Yes
|
| 21. Are you clumsy? |
No
Yes
|
| 22. Do you have problems concentrating or thinking clearly, feel spacey? |
No
Yes
|
| 23. Do you have a cough? |
No
Yes
|
| 24. Do you crave sugar or carbs? |
No
Yes
|
| 25. Do you have a decreased libido? |
No
Yes
|
| 26. Are you depressed? |
No
Yes
|
| 27. Do you have difficulty swallowing? |
No
Yes
|
| 28. Do you experience disequilibrium, spatial disorientation, dizziness, vertigo? |
No
Yes
|
| 29. Do you have double vision or see "floaters"? |
No
Yes
|
| 30. Are your mouth and/or eyes too dry? |
No
Yes
|
| 31. Do you have frequent earaches? |
No
Yes
|
| 32. Do you have endometriosis? |
No
Yes
|
| 33. Do you experience episodic hyperventilation or do you get short of breath easily? |
No
Yes
|
| 34. Do you have eye pain? |
No
Yes
|
| 35. Do you have fainting spells or blackout? |
No
Yes
|
| 36. Do you have extreme fatigue that alternates with periods of normalcy? |
No
Yes
|
| 37. Do you experience fatigue, often accompanied by nonrestorative sleep, generally worsened by exertion? |
No
Yes
|
| 38. Do you have fevers/chills/sweats/feeling hot often? |
No
Yes
|
| 39. Do you have a flushing rash of the face and cheeks? |
No
Yes
|
| 40. Do you have frequent canker sores? |
No
Yes
|
| 41. Do you have a fungal infection of skin and nails? |
No
Yes
|
| 42. Have you experience unusual hair loss? |
No
Yes
|
| 43. Do you have hallucinations? |
No
Yes
|
| 44. Do you get headaches? |
No
Yes
|
| 45. Has your hearing changed? |
No
Yes
|
| 46. Do you experience heart palpitations? |
No
Yes
|
| 47. Do you have a heat/cold intolerance? |
No
Yes
|
| 48. Do you have hypoglycemia or hypoglycemia-like symptoms? |
No
Yes
|
| 49. Are you impotent? |
No
Yes
|
| 50. Do you have tinnitus? (ringing in the ears) |
No
Yes
|
| 51. Do you have increased/severe PMS (premenstrual syndrome)? |
No
Yes
|
| 52. Do you suffer from insomnia? |
No
Yes
|
| 53. Are you intolerant of alcohol? |
No
Yes
|
| 54. Do you have irritable bowel syndrome (diarrhea, nausea, gas, abdominal pain)? |
No
Yes
|
| 55. Do you have isolative tendencies? |
No
Yes
|
| 56. Do you have joint, neck, or muscle pain? |
No
Yes
|
| 57. Do you have low blood pressure? |
No
Yes
|
| 58. Do you have lymph node pain? |
No
Yes
|
| 59. Do you feel like you have the flu? |
No
Yes
|
| 60. Do you have short term memory problems? |
No
Yes
|
| 61. Do you have mitral valve prolapse? |
No
Yes
|
| 62. Do you experience mood swings, excessive irritability, overreaction? |
No
Yes
|
| 63. Do you experience muscle twitching, involuntary movements? |
No
Yes
|
| 64. Do you experience muscle weakness? |
No
Yes
|
| 65. Do you experience nausea or vomiting? |
No
Yes
|
| 66. Do you have night sweats? |
No
Yes
|
| 67. Do you have numbness and/or tingling in extremities? |
No
Yes
|
| 68. Do you have pain in teeth, loose teeth, and endodontal problems, periodontal (gum) disease? |
No
Yes
|
| 69. Has your personality changed? |
No
Yes
|
| 70. Are you sensitive to light? |
No
Yes
|
| 71. Do you feel pressure at base of skull? |
No
Yes
|
| 72. Do you have a pressure sensation behind eyes? |
No
Yes
|
| 73. Do you have pyriform muscle syndrome, causing sciatica? |
No
Yes
|
| 74. Have you lost/gained weight without trying? |
No
Yes
|
| 75. Do you have TMJ syndrome (jaw pain or locking)? |
No
Yes
|
| 76. Have you experienced swelling of nasal passages, swelling of the extremities or eyelids, swollen lymph glands, any swelling, fluid retention? |
No
Yes
|
| 77. Do you have a systemic yeast/fungal infection? |
No
Yes
|
| 78. Do you experience temporary paralysis after sleeping? |
No
Yes
|
| 79. Do you have a subnormal body temperature? |
No
Yes
|
| 80. Do you have sinus pain? |
No
Yes
|
| |