| Please check mark the symptom or activity in the appropriate box |
Never |
Rarely |
Sometimes |
Always |
| 0 For example: Insomnia |
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| 1 General Fatigue or weakness |
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| 2 Difficulty losing weight |
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| 3 Frequent illness/infections |
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| 4 High Stress lfestyle |
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| 5 Smoking |
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| 6 Drink more than 2 cups of coffee/day |
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| 7 Bad breath and/or body odor |
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| 8Constipation |
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| 9 Bags under eyes |
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| 10 Crave sugar, bread, alcohol |
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| 11 Difficulty digesting certain foods |
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| 12 Have used antibiotics in the past 10 years |
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| 13 Allergies |
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| 14 Poor concentration or memory |
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| 15 Belching or burping after meals |
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| 16 Skin/complexion problems |
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| 17 Frequent consumption of red meat |
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| 18 Regular use of dairy products |
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| 19 Heavy alcohol consumption |
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| 20 Exposure to toxins/chemicals |
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| 21 Frequent mood swings |
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| 22 Depressed and/or irritable |
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| 23 Brittle fingernails |
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| 24 Dry, brittle hair, split ends |
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| 25 High fat/high cholesterol diet |
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| 26 Nervousness/anxiety/tension/ worry |
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| 27 Insomnia/restless sleep |
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| 28 Low Fiber diet |
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| 29 Muscle Cramps |
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| 30 Sleepy when sitting up |
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| 31 Female/menstrual cramps |
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| 32 Bronchitis/asthma/ pneumonia/emphysema |
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| 33 Cellulite |
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| 34 Cold hands and feet |
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| 35 Varicose veins |
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| 36 Feeling out of control |
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| 37 Food/chemical sensitivities |
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| 38 Frequent yeast/fungus problems |
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39 Bones break easily, osteoporosis |
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| 40 Too little exercise |
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| 41 Excessive mucous |
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| 42 Short of breath climbing stairs |
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| 43 Tingling in lips, fingers, arms, legs |
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| 44 Chest pains |
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| 45 Very rapid or slow heart beat |
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| 46 Painful, hard or thin bowel movements |
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| 47 Alternating diarrhea/constipation |
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| 48 Recurrent bladder infections |
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| 49 Female: menopause, hot flashes |
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| 50 Female: PMS |
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| 51 Difficult urination |
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| 52 Swollen glands, puffy throat |
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| 53 Lower Abdominal pain |
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| 54 Frequent need to urinate |
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| 55 Joint pain |
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| 56 Sinus inflammation/discharge |
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| 57 Arthritis |
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| 58 Sudden weight gain/loss |
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| 59 Headaches/Migraines |
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| 60 Female: taking birth control pills |
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| 61 Lower back pain |
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| 62 Dry, flaky skin |
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| 63 Drink less than 6 glasses of water/fluids daily |
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| 64 Water retention |
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| 65 Low sex drive |
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| 66 Feeling heavy/bloated after meals |
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| 67 Chronic Cough |
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| Any further information: |
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| Name:
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