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Have You Experienced These Symptoms?
  • This survey will enhance our ability to know exactly how to serve you better. Please take a few minutes to indicate which symptoms you experience at least once or twice a week, once or twice a month or as little as once or twice within a six month period. So I know which of your symptoms are most important to you, I would like you to also check the box to the left of each symptom you are most interested in addressing. It should look like this as you go: Survey Example IMPORTANT: Make sure you click the big red Submit Button at the end of the survey to prevent your answers from being lost.
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  • Have you had one or more in the last:*WeekMonth6 MonthsNone
    Acid foods upset
    Get chilled often
    "Lump" in throat
    Dry mouth, eyes, nose
    Pulse speeds after meal
    Keyed up - fail to calm
    Gag occasionally
    Unable to relax, startles easily
    Extremities cold, clammy
    Strong light irritates
    Occasionally weak urine flow
    Heart pounds after retiring
    "Nervous" stomach
    Appetite reduced occasionally
    Cold sweats often
    Get heated easily
    Nerve discomfort
    Staring, blinks little
    Sour stomach frequent
    Joint stiffness after arising
    Muscle, leg, toe cramps at night
    "Butterfly" stomach, cramps
    Eyes or nose watery
    Eyes blink often
    Eyelids swollen, puffy
    Indigestion soon after meals
    Always hungry, feels lightheaded often
    Digestion rapid
    Vomiting occasionally
    Hoarseness frequent
    Uneven breathing
    Pulse slow
    Gagging reflex slow
    Difficulty swallowing
    Temporary constipation or diarrhea
    "Slow starter"
    Get “chilled”
    Perspire easily
    Sensitive to cold
    Upper respiratory challenges
    Eat when nervous
    Excessive appetite
    Hungry between meals
    Irritable before meals
    Gets "shaky" if hungry
    Fatigue, eating relieves
    "Lightheaded" if meals delayed
    Heart palpitates if meals missed or delayed
    Fatigue in afternoons
    Overeating sweets upsets
    Awaken after few hours sleep – Hard to get back to sleep
    Crave candy or coffee in afternoons
    Moods of “blues” or melancholy
    Craving for sweets or snacks
    Hands and feet go to sleep easily, numbness
    Sigh frequently, "air hunger"
    Aware of "breathing heavily"
    High altitude discomfort
    Opens windows in closed room
    Immune system challenges
    Afternoon "yawner"
    Gets "drowsy" often
    Swollen ankles worse at night
    Muscle cramps, worse during exercise; gets "charlie horses"
    Difficulty catching breath, especially during exercise
    Tightness or pressure in chest, worse on exertion
    Skin discolors easily after impact
    Tendency to anemia
    Noises in head, or “ringing in ears”
    Fatigue upon exertion
    Dizziness
    Dry skin
    Burning feet
    Blurred vision
    Itching skin and feet
    Hair loss
    Occasional skin rashes
    Bitter, metallic taste in mouth in mornings
    Occasional constipation
    Worrier, feels insecure
    Nausea occasionally after eating
    Greasy foods upset
    Stools light–colored
    Skin peels on foot soles
    Discomfort between shoulder blades
    Occasional laxative use
    Stools alternate from soft to watery
    Sneezing attacks
    Dreaming, nightmare type bad dreams
    Bad breath (halitosis)
    Milk products cause upset
    Sensitive to hot weather
    Burning or itching anus
    Crave sweets
    Loss of taste for meat
    Lower bowel gas several hours after eating
    Burning stomach sensations, eating relieves
    Coated tongue
    Pass large amounts of foul-smelling gas
    Indigestion 1/2 to 4 hours after eating
    Watery or loose stool
    Gas shortly after eating
    Stomach "bloating"
    Difficulty sleeping
    On edge
    Can’t gain weight
    Intolerance to heat
    Highly emotional
    Flush easily
    Night sweats
    Thin, moist skin
    Inward trembling
    Heart races
    Increased appetite without weight gain
    Pulse fast at rest
    Eyelids and face twitch
    Irritable and restless
    Canʼt work under pressure
    Increase in weight
    Decrease in appetite
    Fatigue easily
    Ringing in ears
    Sleepy during day
    Sensitive to cold
    Dry or scaly skin
    Temporary constipation
    Mental sluggishness
    Hair coarse, falls out
    Tension in head upon arising wears off during day
    Slow pulse, below 65
    Changing urinary function
    Sounds appear diminished
    Reduced initiative
    Failing memory with age
    Increased sex drive
    Episodes of tension in head
    Decreased sugar tolerance
    Abnormal thirst
    Bloating of abdomen
    Weight gain around hips or waist
    Sex drive reduced or lacking
    Tendency for stomach issues
    Immune system challenges
    Menstrual disorders
    Dizziness
    Headaches
    Hot flashes
    Hair growth on face or body (female)
    Sugar in urine (not diabetes)
    Masculine tendencies (female)
    Weakness, dizziness
    Tired throughout day
    Nails, weak, ridged
    Sensitive skin
    Stiff joints
    Perspiration increase
    Bowel discomfort
    Poor circulation
    Swollen ankles
    Crave salt
    Areas of skin darkening
    Upper respiratory sensitivity
    Weakness after colds, influenza
    Tiredness
    Breathing challenges
    Muscle weakness
    Lack of stamina
    Drowsiness after eating
    Muscular soreness
    Heart races
    Hyper-irritable
    Feeling of a band around your head
    Melancholia (feeling of sadness)
    Swelling of ankles
    Change in urinary function
    Tendency to consume sweets/carbohydrates
    Muscle spasms
    Blurred vision
    Involuntary muscle action
    Numbness
    Night sweats
    Rapid digestion
    Sensitivity to noise
    Redness of palms of hands and bottom of feet
    Visible veins on chest and abdomen
    Hemorrhoids
    Apprehension (feeling that something bad is going to happen)
    Nervousness causing loss of appetite
    Nervousness with indigestion
    Gastritis
    Forgetfulness
    Thinning hair
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  • What is your gender*to order
    Male
    Female
    2
  • *you like
    I also have one or more known or diagnosed conditions.
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