Name
*
First Name
Last Name
Birth Date
*
MM
DD
YYYY
Headaches
0
1
2
3
4
Faintness
0
1
2
3
4
Dizziness
0
1
2
3
4
Insomnia
0
1
2
3
4
Watery of Itchy Eyes
0
1
2
3
4
Swollen, reddened or sticky eyelids
0
1
2
3
4
Bags or dark circles under eyes
0
1
2
3
4
Blurred or tunnel vision
0
1
2
3
4
Itchy Ears
0
1
2
3
4
Earaches, ear infections
0
1
2
3
4
Drainage from ear
0
1
2
3
4
Ringing in ears, hearing loss
0
1
2
3
4
Stuffy nose
0
1
2
3
4
Sinus problems
0
1
2
3
4
Hay fever
0
1
2
3
4
Sneezing attacks
0
1
2
3
4
Excessive Mucus Formation
0
1
2
3
4
Chronic coughing
0
1
2
3
4
Gagging, frequent need to clear throat
0
1
2
3
4
Sore throat, hoarseness, loss of voice
0
1
2
3
4
Swollen or discolored tongue, gums, lips
0
1
2
3
4
Canker sores
0
1
2
3
4
Acne
0
1
2
3
4
Hives, rashes, dry skin
0
1
2
3
4
Hair loss
0
1
2
3
4
Flushing, hot flashes
0
1
2
3
4
Excessive sweating
0
1
2
3
4
Irregular or skipped heartbeat
0
1
2
3
4
Rapid or pounding heartbeat
0
1
2
3
4
Chest pain
0
1
2
3
4
Chest congestion
0
1
2
3
4
Asthma, bronchitis
0
1
2
3
4
Shortness of breath
0
1
2
3
4
Difficulty breathing
0
1
2
3
4
Nausea, vomiting
0
1
2
3
4
Diarrhea
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated feeling
0
1
2
3
4
Belching, passing gas
0
1
2
3
4
Heartburn
0
1
2
3
4
Intestinal/stomach pain
0
1
2
3
4
Pain or aching joints
0
1
2
3
4
Arthritis
0
1
2
3
4
Stiffness or limitation of movement
0
1
2
3
4
Pain or aches in muscles
0
1
2
3
4
Feeling of weakness or tiredness
0
1
2
3
4
Binge eating/drinking
0
1
2
3
4
Craving certain foods
0
1
2
3
4
Excessive weight
0
1
2
3
4
Compulsive Eating
0
1
2
3
4
Water Retention
0
1
2
3
4
Underweight
0
1
2
3
4
Fatigue, sluggishness
0
1
2
3
4
Apathy, lethargy
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Restlessness
0
1
2
3
4
Poor memory
0
1
2
3
4
Confusion, poor comprehension
0
1
2
3
4
Poor concentration
0
1
2
3
4
Poor physical coordiation
0
1
2
3
4
Difficulty making decisons
0
1
2
3
4
Stuttering or stammering
0
1
2
3
4
Slurred speech
0
1
2
3
4
Learning disabilities
0
1
2
3
4
Mood swings
0
1
2
3
4
Anxiety, fear, nervousness
0
1
2
3
4
Anger, irritability, restlessness
0
1
2
3
4
Depression
0
1
2
3
4
Frequent illness
0
1
2
3
4
Frequent or urgent urination
0
1
2
3
4
Genital itch or discharge
0
1
2
3
4
