PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

Digestive Track Heart Nose

__nausea & vomiting __Irregular/Skipped Heartbeat __stuffy nose
__diarrhea __Rapid/Pounding Heartbeat __chronically red/inflamed nose
__constipation __Chest Pain __sinus problems
__bloated feeling __hay fever
__stomach pains or cramps __sneezing attacks
__heart burn __excessive mucous formation
__blood and/or mucous in stools Joints & Muscles
__pains/aches in joints Skin
__arthritis/osteoarthritis __acne
Ears __stiffness/limited movement __itching
__itchy ears __pain/aches in muscles __hives/rash/dry skin
__ear aches/ear infections __feeling weak/tired __hair loss
__drainage from ear __swollen/tender joints __flushing/hot flashes
__ringing in ears __growing pains in legs
__hearing loss __Psoriatic/Gouty Arthritis Weight
__reddening of ears __Rheumatoid Arthritis __binge eating/drinking
__craving certain foods
Lungs __excessive weight
Emotions __chest congestion __compulsive eating
__mood swings __bronchitis __water retention
__anxiety/fear/nervousness __shortness of breath
__anger/irritability/aggressiveness __difficulty breathing General
__argumentative __persistent cough __frequent illness
__frustrated/cries easily __wheezing __frequent/urgent urination
__Depression __genital itch/discharge
__anal itching
Mind
__poor memory Genitourinary
Eyes __difficulty completing projects __kidney problems
__watery or itchy eyes __difficulty with mathematics __urinary tract
__red/swollen/itchy eyelids __underachiever __bladder
__bags or dark circles under eyes __poor/short attention span __yeast infections
__blurred or tunnel vision __confusion
__easily distracted Other Conditions
__difficulty making decisions __Autism
__mild learning Disabilities __A.D.H.D.
Head __A.D.D.
__headaches Mouth & Throat Thrush __Psoriasis
__faintness __chronic coughing __Eczema
__dizziness __gagging/clearing throat often __Auto Immune Disorder
__insomnia/sleep disorder __sore throat/hoarse voice/voice __Chronic Fatigue
__facial flushing loss __Multiple Chemical Sensitivities
__swollen/discolored tongue/lips __Asthma
__canker sores __Congestive Heart Failure
__itching on roof of mouth __Severe Diabetic
Date__________________________ __Severe Depression
__Obsessive Compulsive Disorder
Patient
Name__________________________

91 Cernon St. ● Suite B ● Vacaville, CA 95688 ● (707) 447-8100