Name *

First Name

Last Name

Exhaustion after light exercise *

0

1

Lack of energy *

0

1

Lethargy *

0

1

Lack of sex drive *

0

1

Need for excessive sleep *

0

1

Low blood pressure *

0

1

Rapid heart beat *

0

1

High blood pressure *

0

1

Insomnia *

0

1

Constipation *

0

1

Diarrhea *

0

1

Dizziness or irritability after 6 hours without food *

0

1

Excessive thirst or sweating *

0

1

Frequent food cravings *

0

1

Need for frequent meals *

0

1

Stomach pains *

0

1

Swollen abdomen *

0

1

Poor appetite *

0

1

Vomiting or nausea *

0

1

Need for extreme sweetness, saltiness, or spiciness - bland foods are unappetising *

0

1

Bleeding or tender gums *

0

1

Bloodshot, burning, or gritty eyes *

0

1

Dull or oily hair *

0

1

Dandruff or dry scalp *

0

1

Dry hair or dandruff *

0

1

Eye pains *

0

1

Eye cataracts *

0

1

Tooth decay *

0

1

Teeth grinding *

0

1

Hair loss *

0

1

Headaches or migraines *

0

1

Nosebleeds *

0

1

Desensitized to pungent smells *

0

1

Sore tongue *

0

1

Sensitivity to bright lights *

0

1

Mouth ulcers or cold sores *

0

1

Mouth overly sensitive to hot or cold *

0

1

Poor hair condition *

0

1

Prematurely greying hair *

0

1

Arthritis or osteoporosis *

0

1

Athlete's foot *

0

1

Back pain *

0

1

Joint pain or stiffness *

0

1

Joint inflammation or arthritis *

0

1

Muscle twitching or spasms *

0

1

Muscle cramps, tremors, spasms *

0

1

Muscle weakness *

0

1

Tender or sore muscles *

0

1

Loss of muscle tone *

0

1

Weak bones *

0

1

Sore knees *

0

1

Acne, rashes, or skin infections *

0

1

Burning feet, tender heels *

0

1

Cracked lips *

0

1

Cold hands *

0

1

Cellulite *

0

1

Dry, flaky or itching skin *

0

1

Dermatitis *

0

1

Easy bruising *

0

1

Eczema *

0

1

Excessive or cold sweats *

0

1

Varicose veins *

0

1

Tingling hands *

0

1

Poor skin elasticity *

0

1

Pale skin *

0

1

Red pimples on skin *

0

1

Slow wound-healing *

0

1

Anxiety or tension *

0

1

Depression *

0

1

Irritability *

0

1

Infrequent dream recall *

0

1

Poor concentration *

0

1

Poor memory *

0

1

Nervousness *

0

1

Breast tenderness *

0

1

Frequent colds or infections *

0

1

Fits or convulsions *

0

1

Family history of cancer *

0

1

Infertility *

0

1

Numb, prickly, tingling legs *

0

1

Obesity *

0

1

PMS or breast pain *

0

1

Reduced night vision *

0

1

Split nails *

0

1

Signs of premature aging *

0

1

Thrush or cystitis *

0

1

Water retention *

0

1

Brittle nails *

0

1

Heavy periods or blood loss *

0

1

Anemia *

0

1

White marks on more than two fingernails *

0

1

Stretch marks *

0

1

Dizziness or poor sense of balance *

0

1