Rate each of the following symptoms based on your typical health profile for the specified duration
*
Past month
Past week
Past 48 hours
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Today's Date
*
MM
DD
YYYY
HEAD - Headaches
*
0
1
2
3
4
HEAD - Faintness
*
0
1
2
3
4
HEAD - Dizziness
*
0
1
2
3
4
HEAD - Insomnia
*
0
1
2
3
4
TOTAL
EYES - Watery or itchy eyes
*
0
1
2
3
4
EYES - Swollen, reddened or sticky eyelids
*
0
1
2
3
4
EYES - Bags or dark circles under eyes
*
0
1
2
3
4
EYES - Blurred or tunnel vision
*
0
1
2
3
4
Total
EARS - Itchy ears
0
1
2
3
4
EARS - Ear aches, ear infections
*
0
1
2
3
4
EARS - Drainage from ears
*
0
1
2
3
4
EARS - Ringing in ears, hearing loss
*
0
1
2
3
4
TOTAL
NOSE - Stuffy nose
*
0
1
2
3
4
NOSE - Sinus problems
*
0
1
2
3
4
NOSE - Hay fever
*
0
1
2
3
4
NOSE - Sneezing attacks
*
0
1
2
3
4
NOSE - Excessive mucus formation
*
0
1
2
3
4
TOTAL
MOUTH/THROAT - Chronic coughing
*
0
1
2
3
4
MOUTH/THROAT - Gagging, frequent need to clear throat
*
0
1
2
3
4
MOUTH/THROAT - Sore throat, hoarseness, loss of voice
*
0
1
2
3
4
MOUTH/THROAT - Swollen or discolored tongue, gums, lips
*
0
1
2
3
4
MOUTH/THROAT - Canker sores
*
0
1
2
3
4
TOTAL
*
SKIN - Acne
*
0
1
2
3
4
SKIN - Hives, rashes, dry skin
*
0
1
2
3
4
SKIN - Hair loss
*
0
1
2
3
4
SKIN - Flushing, hot flashes
*
0
1
2
3
4
SKIN - Excessive sweating
*
0
1
2
3
4
TOTAL
*
HEART - Chest pain
*
0
1
2
3
4
HEART - Irregular or skipped heartbeat
*
0
1
2
3
4
HEART - Rapid or pounding heartbeat
*
0
1
2
3
4
TOTAL
*
LUNGS - Chest congestion
*
0
1
2
3
4
LUNGS - Asthma, bronchitis
*
0
1
2
3
4
LUNGS - Shortness of breath
*
0
1
2
3
4
LUNGS - Difficulty breathing
*
0
1
2
3
4
TOTAL
*
DIGESTIVE TRACT - Nausea, vomiting
*
0
1
2
3
4
DIGESTIVE TRACT - Diarrhea
*
0
1
2
3
4
DIGESTIVE TRACT - Constipation
*
0
1
2
3
4
DIGESTIVE TRACT - Bloated feeling
*
0
1
2
3
4
DIGESTIVE TRACT - Belching, passing gas
*
0
1
2
3
4
DIGESTIVE TRACT - Heartburn
*
0
1
2
3
4
DIGESTIVE TRACT - Intestinal/stomach pain
*
0
1
2
3
4
TOTAL
*
JOINTS/MUSCLE - Pain or aches in joints
*
0
1
2
3
4
JOINTS/MUSCLE - Arthritis
*
0
1
2
3
4
JOINTS/MUSCLE - Stiffness or limitation of movement
*
0
1
2
3
4
JOINTS/MUSCLE - Feeling of weakness or tiredness
*
0
1
2
3
4
JOINTS/MUSCLE - Pain or aches in muscles
*
0
1
2
3
4
TOTAL
WEIGHT - Binge eating/drinking
*
0
1
2
3
4
WEIGHT - Craving certain foods
*
0
1
2
3
4
WEIGHT - Excessive weight
*
0
1
2
3
4
WEIGHT - Water retention
*
0
1
2
3
4
WEIGHT - Underweight
*
0
1
2
3
4
WEIGHT - Compulsive eating
*
0
1
2
3
4
TOTAL
*
ENERGY/ACTIVITY - Fatigue, sluggishness
*
0
1
2
3
4
ENERGY/ACTIVITY - Apathy, lethargy
*
0
1
2
3
4
ENERGY/ACTIVITY - Hyperactivity
*
0
1
2
3
4
ENERGY/ACTIVITY - Restlessness
*
0
1
2
3
4
TOTAL
MIND - Poor memory
*
0
1
2
3
4
MIND - Confusion, poor comprehension
*
0
1
2
3
4
MIND - Difficulty in making decisions
*
0
1
2
3
4
MIND - Stuttering or stammering
*
0
1
2
3
4
MIND - Slurred speech
*
0
1
2
3
4
MIND - Learning Disabilities
*
0
1
2
3
4
MIND - Poor concentration
*
0
1
2
3
4
MIND - Poor physical coordination
*
0
1
2
3
4
TOTAL
*
EMOTIONS - Mood swings
*
0
1
2
3
4
EMOTIONS - Anxiety, fear, nervousness
*
0
1
2
3
4
EMOTIONS - Anger, irritability, aggressiveness
*
0
1
2
3
4
EMOTIONS - Depression
*
0
1
2
3
4
TOTAL
*
OTHER - Frequent illness
*
0
1
2
3
4
OTHER - Frequent or urgent urination
*
0
1
2
3
4
OTHER - Genital itch or discharge
*
0
1
2
3
4
TOTAL
*
GRAND TOTAL (add all totals together)
*
1. Are you presently using prescription drugs?
*
Yes (1 pt.)
No (0 pt.)
If yes, how many are you currently taking? (1 pt. each)
2. Are you presently taking one of more of the following over the counter drugs? Cimetidine (2 pts.) Acetaminophen (2 pts.) and/or Estradiol (2 pts.)
*
3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them?:
*
Experience side effects, drug(s) is (are) efficacious at lowered dose(s) (3 pts.)
Experience side effects, drug(s) is (are) efficacious at usual dose(s) (2 pts.)
Experience no side effects, drug(s) is (are) usually not efficacious (2 pts.)
Experience no side effects, drug(s) is (are) usually efficacious (0 pt.)
4. Do you currently use or within the last 6 months had you regularly used tobacco products?
*
Yes (2 pts.)
No (0 pt.)
5. Do you have strong negative reactions to caffeine or caffeine containing products?
*
Yes (1 pt.)
No (0 pt.)
Don't know (0 pt.)
6. Do you commonly experience "brain fog", fatigue, or drowsiness?
*
Yes (1 pt.)
No (0 pt.)
7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
*
Yes (1 pt.)
No (0 pt.)
Don't know (0 pt.)
8. Do you feel ill after you consume even small amounts of alcohol?
*
Yes (1 pt.)
No (0 pt.)
Don't know (0 pt.)
9. Do you have a personal history of: (check all that apply)
10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
*
Yes (1 pt.)
No (0 pt.)
11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar vegetables, etc?
*
Yes (1 pt.)
No (0 pt.)
Don't know (0 pt.)
GRAND TOTAL
1. Do you have a history or currently have kidney dysfunction?
*
Yes
No
2. Have you ever been diagnosed with a condition known as hyperkalemia?
*
Yes
No
3. Are you currently on diuretics or blood pressure medication?
*
Yes
No
