NOTE: If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring / 2 for moderate or regularly occurring / 3 for severe or occurring all the time. Please leave blank if the symptom/statement does not apply.
symptoms or activities
Occurring
General fatigue or weakness
Frequent illness/infections
Drinking more than 2 cups of coffee/day
Bad breath and/or body odour
Crave sugars, bread, alcohol
Difficulty digesting certain foods
Have used antibiotics in past 10 years
Poor concentration or memory
Belching or burping after meals
Frequent consumption of red meat
Regular use of dairy products
Heavy alcohol consumption
Exposure to toxins/chemicals
Depressed and/or irritable
Dry, brittle hair, split ends
High fat/high cholesterol diet
Nervousness/anxiety/tension/worry
Bronchitis/asthma/pneumonia/emphysema
Food/chemical sensitivities
Frequent yeast/fungus problems
Bones break easily, osteoporosis
Short of breath climbing stairs
Tingling in lips, fingers, arms, legs
Very rapid or slow heart beat
Painful, hard or thin bowel movements
Alternating constipation/diarrhea
Recurrent bladder infections
Female: Menopause, hot flashes
Swollen glands, puffy throat
Sinus inflammation/discharge
Female: Taking birth control pills
Drink less than 6 glasses of fluids/day
Feeling heavy/bloated after meals
