Health Profile

Health Profile

Please complete the following health questionnaire to the best of your ability. Fill in your basic health information and then rate each of the symptoms listed as:

0 = Never or almost never have the symptom 3 = Frequently have it, effect is not severe

1 = Occasionally have it, the effect is not severe 4 = Frequently have it, effect is severe

2 = Occasionally have it, the effect is severe

Name *
E-mail Address *
Date
Age
Height
Weight
List any medications, herbal or nutritional supplements (vitamins, minerals) you are currently taking
Do you have any current diagnosed medical conditions?
Headaches
Faintness
Dizziness
Insomnia
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums or lips
Cancer sores
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Pains or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Binge eating/drinking
Craving certain Foods
Excessive weight
Compulsive eating
Water retention
Underweight
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical condition
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Frequent illness
Frequent or urgent urination
Genital itch or discharge

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