Medical Symptoms Questionaire

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Medical Symptoms Questionaire

* Indicates required field

Name *

First

Last

Phone Number *

Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Height *

Weight *

Marital Status *

Number of Children *

Email *

Date of Birth *

Gender *

Check all conditions/symptoms that apply to you within the past 30 days

Do you currently suffer from HEAD *

Frequent Headaches Dizziness Faintness Insomnia

Do you currently suffer from; Eyes *

Watery or Itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (does not include near or farsightedness

Comments *

Comment *

Do you currently suffer from; Ears *

Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss

Do you suffer from; Nose *

Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation

Comment *

Do you suffer from; Skin *

Acne Hives,rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating

Do you suffer from; Mouth/Throat *

Chronic coughing Gagging,frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips Canker sores

Comment *

Do you suffer from; Heart *

Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain

Do you suffer from; Lungs *

Chest congestion Asthma,bronchitis Shortness of breath Difficulty breathing

Comment *

Do you suffer from; Digestive tract *

Nausea, vomitng Diarrhea Consipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain

Do you suffer from; Joint/Muscle *

Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness

Comment *

Do you suffer from; Weight *

Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight

Comment *

Do you suffer from; Energy/Activity *

Fatigue, slugishness Apathy,lethargy Hyperactivity Restlessness

Comment *

Do you suffer from; Mind *

Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speach Learning disabilities

Do you suffer from; Emotions *

Mood swings Anxiety, fear,nervousness Anger,irritability, aggtressiveness Depression