Health Questionnaire WelcomeThis questionnaire will help you determine if you should get help for certain symptoms you may be experiencing.Each question will present example symptoms for a specific area, and you will rate your symptoms based on your typical health profile for the Past 30 Days. The rating options will be a combination of frequency & severityThe survey should take less than 5 minutes of your time.*You will need to have Javascript enabled for this questionnaire.HeadFaintness, Headaches, Dizziness Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereEyesItchy, Watery, Yellowing, or Reddened eyesSwollen, Reddened, or Sticky eyelidsBags, Dark CirclesProblems with Night Vision, Peripheral Vision, or Blurriness. Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereEarsItchy EarsEaraches, InfectionsDrainageRinging, Hearing Loss Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereNoseSinus Problems, Stuffy, Excessive Mucus, Hay Fever, Sneezing Attacks, Loss of sense of smell. Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereMouth/ThroatChronic Cough, Sore Throat, HoarsenessGagging/throat clearingSwollen/discolored tongueCoating on tongue, BurningChewing, or Swallowing problemsCanker Sores, Fever BlistersCracked lips Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereHairThinning, or LossLoss of outer eyebrow hairPremature greyingEasy hair pluckability Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereSkinAcne, Hives, RashesDry skin, Bumps, FlushingExcessive Sweating Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereNailsSpoon shaped, Brittle, CrackingDiscolored, or White Spots, Lines/Stripes Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereImmuneColds, Flu, Chronic Infections Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereHeartIrregular/skipped beatsRapid/pounding beatsChest Pain Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereLungsChest congestionAsthma or BronchitisShortness of breathDifficulty breathing Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereEnergy/SleepFatigue, LethargyHyperactivity, InsomniaSleep disruptions Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereDigestive Tract/Gastrointestinal (GI)Nausea, VomitingDiarrhea, ConstipationBloating, BelchingGas/FlatulenceHeartburnUpper GI Pain, Lower Abdominal Pain Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereJoint/Muscle/BoneArthritisStiffness/Limited movementPains or aches in musclesFeelings weakness, or Loss of strengthRestless legsBone Pain, or Broken Bones Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereWeightUnder, or Over weight. Obesity.Weight Loss or Gain (>5-10lbs)Fluid retention Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereGenitourinaryFrequent, or urgent urinationItchingDischargeIncontinence Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereNeurologicalPain or Aches in jointsPoor Concentration/Brain fogPoor Memory, or ConfusionPoor Physical Coordination, Loss of BalanceTingling in hands or feetStuttering, Stammering, or Slurred speech. Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereEmotionsMood swingsAnxiety, Worry, Fear, NervousnessAnger, Iffitability, AgitaitonDepression Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, SevereResultsYour total score is Overall your symptoms are Get in touch today to reduce your symptoms:Name: * Email: * Message: *Human Verification: * 1 plus 2 = Previous Next
