Hearthstone Holistic Health Nutrient Deficiency Form

These forms are not meant as a diagnosis or as a replacement for medical care.

Please check off the food element that you are missing.

It will be amazing how all of your symptoms can tie together.

Protein   Iron  
1 Excess Fluid Retention 1 Lack of energy or strength
2 Nausea or dizziness 2 Dizziness
3 Poor coordination 3 Cravings for ice
4 General overall weakness 4 Pale lower eyelid
5 Anemia 5 Tachycardia
6 Cataracts 6 Spoon shaped nails
7 Cuticles tear easily    
8 Hair dull, sparse. loose and falling    
Essential Fatty Acids   Magnesium  
1 Rough, dry or scaly skin 1 Muscle spasms or tremors
2 Dry, brittle hair 2 Gall stones
3 Eczema 3 Cravings for chocolate
4 Psoriasis 4 Irregular heartbeat
5 Poor memory 5 Excessive body odor
6 Irregular menstrual periods    
Calcium   Manganese  
1 Osteoporosis 1 Joint pains
2 Bones break easily 2 Bursitis, tendonitis
3 Irregular heartbeat 3 Prone to injuries
4 Brittle nails 4 Weak knees
5 Muscle cramps 5 Creaking or clicking of joints
6 Crowded teeth 6 Weak muscles
7 Insomnia    
Chromium   Potassium  
1 High blood cholesterol 1 High blood pressure
2 Intolerance to alcohol 2 Swelling of ankles
3 Diabetic or hypoglycemic 3 Always thirsty
4 Overweight 4 Irregular heartbeat
5 Sugar cravings 5 Muscular weakness & fatigue
6 Chronic dieter    
7 Kidney disease Selenium  
    1 Dry hair
Iodine   2 Thin hair
1 Fatigue, extreme lack of energy 3 Weak immunity, frequent infections
2 Dry hair 4 Dandruff
3 Thyroid problems: goiter 5 Cataracts
4 Overweight    
5 Constipation Zinc  
6 Hands and feet always cold 1 White spots on fingernails
7 Brittle nails 2 Acne
    3 Male: Poor sperm production
    4 Frequent Infections
    5 Poor Dream recall
    6 Cuts/wounds heal slowly
    7 Loss of sense of smell or taste
    8 Thinning hair
    9 Red stretch marks

So all of that was minerals and now we move on to vitamins. Again, please tick off what you are experiencing physically.

Vitamin A   B12 (Cobalamin)
1 Hard little bumps around elbows 1 Fatigue or weakness
2 Dry or rough skin 2 Lightheadedness or dizziness
3 Dry hair, acne 3 Heart palpitation
4 Poor night vision 4 Shortness of breath, chest pain
5 Susceptibility to respiratory infections 5 Sore, red glazed-looking tongue
6 Slow light to dark adaptation 6 Irritability: inability to concentrate
7 Eyes unable to produce tears 7 Ringing in ears (tinnitus)
8 Weak tooth enamel 8 Nausea and diarrhea
9 Dandruff 9 Memory loss, forgetfulness
    10 Poor coordination
B1 (Thiamine)   Biotin  
1 Fatigue 1 Skin disorders
2 Apathy, depression 2 Smooth pale tongue
3 Loss of knee jerk response 3 Loss of appetite
4 Irregular heartbeat 4 Pale fingernails
5 Gastrointestinal disorders 5 Irregular heartbeat
    6 Severe depression
B2 (Riboflavin)   7 Mild anemia
1 Dry skin around nose and lips 8 Hair loss
2 Cracks, sores around corner of mouth    
3 Bloodshot or itchy eyes Choline  
4 Cataracts 1 High blood pressure
5 Eyes sensitive to light 2 High blood cholesterol
6 Abnormal hair loss 3 Overweight
7 Trembling painful purplish red tongue 4 Eczema
    5 Bleeding ulcer
B3 ( Niacin)   6 Disoriented, memory loss
1 Sore tongue 7 Difficulty losing weight
2 Fatigue    
3 Loss of appetite Folic Acid  
4 Skin disorders 1 Paleness
5 Swelling of mouth 2 Sore red tongue
6 Smooth tongue 3 Bleeding gums
7 Mental confusion 4 Diarrhea
8 Loss of sense of humor 5 Insomnia
9 Canker sores in mouth 6 Irritability
    7 Fatigue
B6 (Pyridoxine)      
1 Anemia P.A.B.A. (para-amino-benzoic-acid)  
2 Irritability, poor dream recall 1 Constipation
3 Sore thumbs, kidney stones 2 General gastrointestinal disorders
4 Female: acne worse during menstruation 3 Premature greying
5 Female: morning sickness during pregnancy 4 Depression and irritability
    5 Fatigue
    6 Headache
B5 (Pantothenic Acid)   Vitamin C  
1 Abdominal pain 1 Bleeding gums
2 Anorexia 2 Urinary tract infections
3 Nausea 3 Abnormal nose bleeds
4 Burning feet 4 Slow healing of wounds
5 Depression and irritability 5 General weakness
6 Headache 6 Shortness of breath
7 Nervousness 7 Skin bruises easily
8 Purplish red tongue 8 Ruptured blood vessels in eyes
    9 Excessive hair loss
    10 Aching bones and joints
Vitamin D      
1 Muscle weakness    
2 Pain in ribs, spine and legs Vitamin E (tocopherol)  
3 Malformation of bones 1 Heart disease
4 Osteomalacia 2 Premature aging
5 Osteoporosis 3 Weakness
6 Muscle cramps 4 Irritability
7 Rickets, insomnia 5 Diarrhea
8 Nearsightedness (myopia) 6 Poor skin condition
    7 Brittle hair
8 Muscle wasting

 

 

Name: Email:

Phone number:

 

Back to Home Page