Health Questionnaire Welcome This 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 & severity The survey should take less than 5 minutes of your time. *You will need to have Javascript enabled for this questionnaire. Head Faintness, Headaches, Dizziness Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Eyes Itchy, Watery, Yellowing, or Reddened eyes Swollen, Reddened, or Sticky eyelids Bags, Dark Circles Problems with Night Vision, Peripheral Vision, or Blurriness. Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Ears Itchy Ears Earaches, Infections Drainage Ringing, Hearing Loss Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Nose Sinus 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, Severe Mouth/Throat Chronic Cough, Sore Throat, Hoarseness Gagging/throat clearing Swollen/discolored tongue Coating on tongue, Burning Chewing, or Swallowing problems Canker Sores, Fever Blisters Cracked lips Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Hair Thinning, or Loss Loss of outer eyebrow hair Premature greying Easy hair pluckability Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Skin Acne, Hives, Rashes Dry skin, Bumps, Flushing Excessive Sweating Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Nails Spoon shaped, Brittle, Cracking Discolored, or White Spots, Lines/Stripes Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Immune Colds, Flu, Chronic Infections Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Heart Irregular/skipped beats Rapid/pounding beats Chest Pain Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Lungs Chest congestion Asthma or Bronchitis Shortness of breath Difficulty breathing Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Energy/Sleep Fatigue, Lethargy Hyperactivity, Insomnia Sleep disruptions Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Digestive Tract/Gastrointestinal (GI) Nausea, Vomiting Diarrhea, Constipation Bloating, Belching Gas/Flatulence Heartburn Upper GI Pain, Lower Abdominal Pain Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Joint/Muscle/Bone Arthritis Stiffness/Limited movement Pains or aches in muscles Feelings weakness, or Loss of strength Restless legs Bone Pain, or Broken Bones Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Weight Under, 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, Severe Genitourinary Frequent, or urgent urination Itching Discharge Incontinence Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Neurological Pain or Aches in joints Poor Concentration/Brain fog Poor Memory, or Confusion Poor Physical Coordination, Loss of Balance Tingling in hands or feet Stuttering, Stammering, or Slurred speech. Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Emotions Mood swings Anxiety, Worry, Fear, Nervousness Anger, Iffitability, Agitaiton Depression Never Rarely, Effect Not Severe Occasionally, Not Severe Occasionally, Severe Frequently, Not Severe Frequently, Severe Results Your 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
