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 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, ZincHeadaches 0 1 2 Faintness 0 1 2 Dizziness 0 1 2 Insomnia 0 1 2 EYESPossible deficiency of: Alpha Lipoic AcidWatery or itchy eyes 0 1 2 Swollen, reddened or sticky eyelids 0 1 2 Bags or dark circles under eyes 0 1 2 Blurred or tunnel vision 0 1 2 EARSItchy ears 0 1 2 Earaches, ear infections 0 1 2 Drainage from ear 0 1 2 Ringing in ears 0 1 2 Hearing loss 0 1 2 NOSEStuffy nose 0 1 2 Sinus problems 0 1 2 Hay Fever 0 1 2 Sneezing attacks 0 1 2 Excessive Mucus formation 0 1 2 MOUTH / THROATChronic coughing 0 1 2 Gagging 0 1 2 Frequent need to clear throat 0 1 2 Sore throat 0 1 2 Hoarseness or loss of voice 0 1 2 Swollen tongue, gums, lips 0 1 2 Discolored tongue, gums, lips 0 1 2 Canker sores 0 1 2 Cold sores 0 1 2 SKIN / 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, ZincAcne 0 1 2 Hives, rashes, dry skin 0 1 2 Hair loss / brittle hair 0 1 2 Flushing, hot flashes 0 1 2 Excessive sweating 0 1 2 Itchy skin or scalp 0 1 2 Dry or Oily skin 0 1 2 Bruising 0 1 2 HEARTPossible deficiency of: ALA, Potassium, Linoleic, B1, IronChest pain 0 1 2 Shoulder or arm pain 0 1 2 Irregular or skipped heartbeat 0 1 2 Rapid or pounding heartbeat 0 1 2 Poor circulation / Cold hands & feet 0 1 2 Swollen legs / ankles 0 1 2 LUNGSChest congestion 0 1 2 Asthma 0 1 2 Bronchitis 0 1 2 Shortness of breath 0 1 2 Difficulty breathing 0 1 2 DIGESTIVE / METABOLISMPossible deficiency of: Potassium, Alpha Lipoic Acid, AA-6, B3, E, GLA-6, Glutamine, AnthocyanidinsNausea 0 1 2 Vomiting 0 1 2 Diarrhea 0 1 2 Constipation 0 1 2 Belching / passing gas 0 1 2 Bloated feeling 0 1 2 Heartburn / Acid Reflux 0 1 2 Indigestion 0 1 2 Intestinal / stomach pain 0 1 2 Food Intolerance 0 1 2 Blood sugar spikes a/o crashes 0 1 2 JOINTS / MUSCLESPossible deficiency of: Copper, Calcium, D, Manganese, Potassium, Protein, Sodium, Sulphur, DHA-3, EPA-3, Histidine, CO-Enzyme Q10, ValinePain or Aches in joints 0 1 2 Arthritis 0 1 2 Stiffness or Limitation of movement 0 1 2 Feeling of weakness or tiredness 0 1 2 Pain or Aches in muscles 0 1 2 Tremors / Muscle spasms 0 1 2 Poor Coordination 0 1 2 WEIGHT / HORMONESPossible deficiency of: Glutamine, Phenylalanine, Tryptophan, Alpha Lipoic Acid, CO-Enzyme Q10, Anthocyanidins, Magnesium, Phosphorus, ZincBinge eating / drinking 0 1 2 Craving certain foods 0 1 2 Wake up starving 0 1 2 Excessive Weight (even if dieting) 0 1 2 Weight gain / obesity 0 1 2 Under weight 0 1 2 Water retention 0 1 2 Compulsive eating 0 1 2 Restrictive eating 0 1 2 Excessive appetite (high or low) 0 1 2 JOINTS / MUSCLESPossible deficiency of: B2, B5, D3, Calcium, Selenium, Copper, Iron, ChromiumFatigue / sluggishness 0 1 2 Apathy / Lethargy 0 1 2 Hyperactivity 0 1 2 Restlessness 0 1 2 MINDPoor memory 0 1 2 Poor comprehension 0 1 2 Confusion / Indecision 0 1 2 Difficulty in making decisions 0 1 2 Stuttering / Stammering 0 1 2 Slurred speech 0 1 2 Learning / Behavioral disabilities 0 1 2 Poor concentration 0 1 2 Poor physical coordination 0 1 2 EMOTIONSPossible deficiency of: B5, B6, D3, Lithium, DHA, Serine, Cysteine, ChromiumMood swings 0 1 2 Depression 0 1 2 Anxiety 0 1 2 Fear 0 1 2 Nervousness 0 1 2 Anger 0 1 2 Irritability 0 1 2 Aggressiveness 0 1 2 Impulsiveness 0 1 2 Compulsiveness 0 1 2 Slurred speech 0 1 2 OTHERFrequent Illness 0 1 2 Frequent or urgent urination 0 1 2 Female Reproductive issues 0 1 2 Male Reproductive issues 0 1 2 Genital itch or discharge 0 1 2 Unexplained symptoms 0 1 2 "Just not feeling right" 0 1 2
