Symptoms Form

First Name
Last Name
Date of Birth Date of Birth / MM / DD YYYY
Height (inches)
Weight (lbs)
Email
Phone
Address
City
State
Zip Code
SYMPTOMS

Please indicate the symptoms you are experiencing as 0(none), 1(mild), 2(moderate), 3(severe).

For example, if you are moderately anxious you would indicate this by checking 2 next to 'anxious'.

All Individuals
All Individuals	0	1	2	3
Difficulty Concentrating	Difficulty Concentrating0	Difficulty Concentrating1	Difficulty Concentrating2	Difficulty Concentrating3
Increased Forgetfulness	Increased Forgetfulness0	Increased Forgetfulness1	Increased Forgetfulness2	Increased Forgetfulness3
Foggy Thinking	Foggy Thinking0	Foggy Thinking1	Foggy Thinking2	Foggy Thinking3
Tearful	Tearful0	Tearful1	Tearful2	Tearful3
Depressed	Depressed0	Depressed1	Depressed2	Depressed3
Mood Swings	Mood Swings0	Mood Swings1	Mood Swings2	Mood Swings3
Fluid Retention / Bloating	Fluid Retention / Bloating0	Fluid Retention / Bloating1	Fluid Retention / Bloating2	Fluid Retention / Bloating3
Stress	Stress0	Stress1	Stress2	Stress3
Anxious	Anxious0	Anxious1	Anxious2	Anxious3
Morning Fatigue	Morning Fatigue0	Morning Fatigue1	Morning Fatigue2	Morning Fatigue3
Afternoon Fatigue	Afternoon Fatigue0	Afternoon Fatigue1	Afternoon Fatigue2	Afternoon Fatigue3
Evening Fatigue	Evening Fatigue0	Evening Fatigue1	Evening Fatigue2	Evening Fatigue3
Excessive Worry	Excessive Worry0	Excessive Worry1	Excessive Worry2	Excessive Worry3
Difficulty Falling Asleep	Difficulty Falling Asleep0	Difficulty Falling Asleep1	Difficulty Falling Asleep2	Difficulty Falling Asleep3
Difficulty Staying Asleep	Difficulty Staying Asleep0	Difficulty Staying Asleep1	Difficulty Staying Asleep2	Difficulty Staying Asleep3
Decreased Stamina	Decreased Stamina0	Decreased Stamina1	Decreased Stamina2	Decreased Stamina3
Diminished Motivation	Diminished Motivation0	Diminished Motivation1	Diminished Motivation2	Diminished Motivation3
Fibromyalgia	Fibromyalgia0	Fibromyalgia1	Fibromyalgia2	Fibromyalgia3
Allergies	Allergies0	Allergies1	Allergies2	Allergies3
Headaches/Migraines	Headaches/Migraines0	Headaches/Migraines1	Headaches/Migraines2	Headaches/Migraines3
Sugar Cravings	Sugar Cravings0	Sugar Cravings1	Sugar Cravings2	Sugar Cravings3
Addictive Behavior	Addictive Behavior0	Addictive Behavior1	Addictive Behavior2	Addictive Behavior3
Obsessive Behaviors (OCD)	Obsessive Behaviors (OCD)0	Obsessive Behaviors (OCD)1	Obsessive Behaviors (OCD)2	Obsessive Behaviors (OCD)3
Craving Food, Alcohol, Tobacco or Other	Craving Food, Alcohol, Tobacco or Other0	Craving Food, Alcohol, Tobacco or Other1	Craving Food, Alcohol, Tobacco or Other2	Craving Food, Alcohol, Tobacco or Other3
Constipation	Constipation0	Constipation1	Constipation2	Constipation3
Goiter	Goiter0	Goiter1	Goiter2	Goiter3
Cold Body Temperature	Cold Body Temperature0	Cold Body Temperature1	Cold Body Temperature2	Cold Body Temperature3
Hair Dry or Brittle	Hair Dry or Brittle0	Hair Dry or Brittle1	Hair Dry or Brittle2	Hair Dry or Brittle3
Nails Breaking or Brittle	Nails Breaking or Brittle0	Nails Breaking or Brittle1	Nails Breaking or Brittle2	Nails Breaking or Brittle3
Slow Pulse Rate	Slow Pulse Rate0	Slow Pulse Rate1	Slow Pulse Rate2	Slow Pulse Rate3
Rapid Heartbeat	Rapid Heartbeat0	Rapid Heartbeat1	Rapid Heartbeat2	Rapid Heartbeat3
Heart Fluttering/Palpitations	Heart Fluttering/Palpitations0	Heart Fluttering/Palpitations1	Heart Fluttering/Palpitations2	Heart Fluttering/Palpitations3
Incontinence	Incontinence0	Incontinence1	Incontinence2	Incontinence3
Hot Flashes	Hot Flashes0	Hot Flashes1	Hot Flashes2	Hot Flashes3
Night Sweats	Night Sweats0	Night Sweats1	Night Sweats2	Night Sweats3
Acne	Acne0	Acne1	Acne2	Acne3
Scalp Hair Loss	Scalp Hair Loss0	Scalp Hair Loss1	Scalp Hair Loss2	Scalp Hair Loss3
Weight Gain-Hips	Weight Gain-Hips0	Weight Gain-Hips1	Weight Gain-Hips2	Weight Gain-Hips3
Weight Gain-Waist	Weight Gain-Waist0	Weight Gain-Waist1	Weight Gain-Waist2	Weight Gain-Waist3
High Cholesterol	High Cholesterol0	High Cholesterol1	High Cholesterol2	High Cholesterol3
Decreased Libido	Decreased Libido0	Decreased Libido1	Decreased Libido2	Decreased Libido3
Decreased Muscle Mass	Decreased Muscle Mass0	Decreased Muscle Mass1	Decreased Muscle Mass2	Decreased Muscle Mass3
Burned Out Feeling	Burned Out Feeling0	Burned Out Feeling1	Burned Out Feeling2	Burned Out Feeling3
Sore Muscles	Sore Muscles0	Sore Muscles1	Sore Muscles2	Sore Muscles3
Increased Joint Pain	Increased Joint Pain0	Increased Joint Pain1	Increased Joint Pain2	Increased Joint Pain3
Neck or Back Pain	Neck or Back Pain0	Neck or Back Pain1	Neck or Back Pain2	Neck or Back Pain3
Bone Loss	Bone Loss0	Bone Loss1	Bone Loss2	Bone Loss3
Thinning Skin	Thinning Skin0	Thinning Skin1	Thinning Skin2	Thinning Skin3
Aches and Pains	Aches and Pains0	Aches and Pains1	Aches and Pains2	Aches and Pains3
IBS	IBS0	IBS1	IBS2	IBS3
Reflux	Reflux0	Reflux1	Reflux2	Reflux3
Gas/Bloating	Gas/Bloating0	Gas/Bloating1	Gas/Bloating2	Gas/Bloating3
Sensitive to Smells	Sensitive to Smells0	Sensitive to Smells1	Sensitive to Smells2	Sensitive to Smells3
Chemical Sensitivities	Chemical Sensitivities0	Chemical Sensitivities1	Chemical Sensitivities2	Chemical Sensitivities3

Women Only
Women Only	0	1	2	3
Vaginal Dryness	Vaginal Dryness0	Vaginal Dryness1	Vaginal Dryness2	Vaginal Dryness3
Irregular Periods	Irregular Periods0	Irregular Periods1	Irregular Periods2	Irregular Periods3
Uterine Fibroids	Uterine Fibroids0	Uterine Fibroids1	Uterine Fibroids2	Uterine Fibroids3
Tender Breasts	Tender Breasts0	Tender Breasts1	Tender Breasts2	Tender Breasts3
Fibrocystic Breasts	Fibrocystic Breasts0	Fibrocystic Breasts1	Fibrocystic Breasts2	Fibrocystic Breasts3
Increased Facial/Body Hair	Increased Facial/Body Hair0	Increased Facial/Body Hair1	Increased Facial/Body Hair2	Increased Facial/Body Hair3

Last Menses Last Menses / MM / DD YYYY

MEN ONLY
MEN ONLY	0	1	2	3
Decreased Urine Flow	Decreased Urine Flow0	Decreased Urine Flow1	Decreased Urine Flow2	Decreased Urine Flow3
Increased Urinary Urge	Increased Urinary Urge0	Increased Urinary Urge1	Increased Urinary Urge2	Increased Urinary Urge3
Prostate Problems	Prostate Problems0	Prostate Problems1	Prostate Problems2	Prostate Problems3
Decreased Erections	Decreased Erections0	Decreased Erections1	Decreased Erections2	Decreased Erections3

Additional Comments/Concerns:
File Uploads (i.e. test results, blood work, etc.)

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Symptoms Form

Symptoms Form

SYMPTOMS

All Individuals

All Individuals

Women Only

Women Only

MEN ONLY

MEN ONLY