• SYMPTOMS QUESTIONNAIRE

    This 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.

  • 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 symptom

  • HEAD
    Possible deficiency of: AA-6, Arginine, Alpha Lipoic Acid, B2, B6, C, Calcium, Carotenoids, Eion, Flavonoids, GLA-6, Histidine, K1, K2, Oleic-9, Phytoestrogen, Selenium, Zinc

  • EYES
    Possible deficiency of: Alpha Lipoic Acid

  • EARS

  • NOSE

  • MOUTH / THROAT

  • SKIN / HAIR HORMONE
    Possible deficiency of: AA-6, Arginine, Alpha Lipoic Acid, B2, B6, C, Calcium, Carotenoids, Eion, Flavonoids, GLA-6, Histidine, K1, K2, Oleic-9, Phytoestrogen, Selenium, Zinc

  • HEART
    Possible deficiency of: ALA, Potassium, Linoleic, B1, Iron

  • LUNGS

  • DIGESTIVE / METABOLISM
    Possible deficiency of: Potassium, Alpha Lipoic Acid, AA-6, B3, E, GLA-6, Glutamine, Anthocyanidins

  • JOINTS / MUSCLES
    Possible deficiency of: Copper, Calcium, D, Manganese, Potassium, Protein, Sodium, Sulphur, DHA-3, EPA-3, Histidine, CO-Enzyme Q10, Valine

  • WEIGHT / HORMONES
    Possible deficiency of: Glutamine, Phenylalanine, Tryptophan, Alpha Lipoic Acid, CO-Enzyme Q10, Anthocyanidins, Magnesium, Phosphorus, Zinc

  • JOINTS / MUSCLES
    Possible deficiency of: B2, B5, D3, Calcium, Selenium, Copper, Iron, Chromium

  • MIND

  • EMOTIONS
    Possible deficiency of: B5, B6, D3, Lithium, DHA, Serine, Cysteine, Chromium

  • OTHER