SYMPTOMS QUESTIONNAIREThis is a subjective survey that is completed based upon your assessment of the presence of any symptoms or body signals that you are experiencing. This questionnaire can reflect what systems are under stress and potential vital nutrients that may be lacking in the body.Not only are we interested in identifying the root neurological cause of symptoms, we want to help you to alleviate the issues/symptoms in the most natural ways possible. Often times this can be accomplished by optimizing your nutritional health in coordination with your chiropractic care. Better genetic expression, thus optimal overall health, can be achieved by determining the essential vitamins, minerals, amino acids, fatty acids and antioxidants that are imbalanced, deficient or inadequate in your body.Name First Last Date Date Format: MM slash DD slash YYYY Rate each of the following symptoms based on your typical profile and experiences within the course of the past three months. Point Scale: 0 = Never or almost never experience the symptom | 1 = Occasionally experience the symptom | 2 = Frequently experience the symptomHEADPossible deficiency of: AA-6, Arginine, Alpha Lipoic Acid, B2, B6, C, Calcium, Carotenoids, Eion, Flavonoids, GLA-6, Histidine, K1, K2, Oleic-9, Phytoestrogen, Selenium, ZincHeadaches012Faintness012Dizziness012Insomnia012EYESPossible deficiency of: Alpha Lipoic AcidWatery or itchy eyes012Swollen, reddened or sticky eyelids012Bags or dark circles under eyes012Blurred or tunnel vision012EARSItchy ears012Earaches, ear infections012Drainage from ear012Ringing in ears012Hearing loss012NOSEStuffy nose012Sinus problems012Hay Fever012Sneezing attacks012Excessive Mucus formation012MOUTH / THROATChronic coughing012Gagging012Frequent need to clear throat012Sore throat012Hoarseness or loss of voice012Swollen tongue, gums, lips012Discolored tongue, gums, lips012Canker sores012Cold sores012SKIN / HAIR HORMONEPossible deficiency of: AA-6, Arginine, Alpha Lipoic Acid, B2, B6, C, Calcium, Carotenoids, Eion, Flavonoids, GLA-6, Histidine, K1, K2, Oleic-9, Phytoestrogen, Selenium, ZincAcne012Hives, rashes, dry skin012Hair loss / brittle hair012Flushing, hot flashes012Excessive sweating012Itchy skin or scalp012Dry or Oily skin012Bruising012HEARTPossible deficiency of: ALA, Potassium, Linoleic, B1, IronChest pain012Shoulder or arm pain012Irregular or skipped heartbeat012Rapid or pounding heartbeat012Poor circulation / Cold hands & feet012Swollen legs / ankles012LUNGSChest congestion012Asthma012Bronchitis012Shortness of breath012Difficulty breathing012DIGESTIVE / METABOLISMPossible deficiency of: Potassium, Alpha Lipoic Acid, AA-6, B3, E, GLA-6, Glutamine, AnthocyanidinsNausea012Vomiting012Diarrhea012Constipation012Belching / passing gas012Bloated feeling012Heartburn / Acid Reflux012Indigestion012Intestinal / stomach pain012Food Intolerance012Blood sugar spikes a/o crashes012JOINTS / MUSCLESPossible deficiency of: Copper, Calcium, D, Manganese, Potassium, Protein, Sodium, Sulphur, DHA-3, EPA-3, Histidine, CO-Enzyme Q10, ValinePain or Aches in joints012Arthritis012Stiffness or Limitation of movement012Feeling of weakness or tiredness012Pain or Aches in muscles012Tremors / Muscle spasms012Poor Coordination012WEIGHT / HORMONESPossible deficiency of: Glutamine, Phenylalanine, Tryptophan, Alpha Lipoic Acid, CO-Enzyme Q10, Anthocyanidins, Magnesium, Phosphorus, ZincBinge eating / drinking012Craving certain foods012Wake up starving012Excessive Weight (even if dieting)012Weight gain / obesity012Under weight012Water retention012Compulsive eating012Restrictive eating012Excessive appetite (high or low)012JOINTS / MUSCLESPossible deficiency of: B2, B5, D3, Calcium, Selenium, Copper, Iron, ChromiumFatigue / sluggishness012Apathy / Lethargy012Hyperactivity012Restlessness012MINDPoor memory012Poor comprehension012Confusion / Indecision012Difficulty in making decisions012Stuttering / Stammering012Slurred speech012Learning / Behavioral disabilities012Poor concentration012Poor physical coordination012EMOTIONSPossible deficiency of: B5, B6, D3, Lithium, DHA, Serine, Cysteine, ChromiumMood swings012Depression012Anxiety012Fear012Nervousness012Anger012Irritability012Aggressiveness012Impulsiveness012Compulsiveness012Slurred speech012OTHERFrequent Illness012Frequent or urgent urination012Female Reproductive issues012Male Reproductive issues012Genital itch or discharge012Unexplained symptoms012"Just not feeling right"012 This iframe contains the logic required to handle Ajax powered Gravity Forms.