Section 7. Liver

     1. Fatty foods upset digestion
No Yes

     2. Gall bladder attacks
No Yes

     3. Indigestion
No Yes

     4. Spicy foods upset digestion
No Yes

     5. Cirrhosis
No Yes

     6. Gall bladder removed
No Yes

     7. Gallstones
No Yes

     8. Hepatitis
No Yes

     9. Jaundice
No Yes

Section 8. Metabolism

     1. Afternoon slump in energy
No Yes

     2. Cannot tolerate cold weather
No Yes

     3. Cannot tolerate hot weather
No Yes

     4. Chronic fatigue
No Yes

     5. Cold feet
No Yes

     6. Cold hands
No Yes

     7. Difficulty losing weight
No Yes

     8. Difficulty getting started in the morning
No Yes

     9. Easily fatigued
No Yes

     10. Feel chilled after eating
No Yes

     11. High thyroid
No Yes

     12. Loss of appetite
None Mild Moderate Severe

     13. Low thyroid
No Yes

     14. Overweight
No Yes

     15. By how many pounds?

     16. Shallow breather
No Yes

     17. Snorer
No Yes

     18. Underweight
No Yes

     19. By how many pounds?

     20. Unexplained weight loss
No Yes

Section 9. Kidneys

     1. Bedwetting
Never Rarely Often Usually Always

     2. Bladder infections
Never Rarely Often Usually Always

     3. Burning sensation when
Never Rarely Often Usually Always

     4. Cloudy urine
Never Rarely Often Usually Always

     5. Dark colored urine
Never Rarely Often Usually Always

     6. Kidney infections
Never Rarely Often Usually Always

     7. Kidney stones
Never Rarely Often Usually Always

     8. Painful urination
Never Rarely Often Usually Always

     9. Strong smelling urine
Never Rarely Often Usually Always

     10. Urge to needlessly
Never Rarely Often Usually Always

     11. often but only in small quantities
Never Rarely Often Usually Always

     12. Gout
No Yes

Section 10. Nervous System

     1. Anxiety attacks
Never Rarely Often Usually Always

     2. Difficulty recalling / cannot recall dreams
Never Rarely Often Usually Always

     3. Confusion
Never Rarely Often Usually Always

     4. Depression
Never Rarely Often Usually Always

     5. Dizziness
Never Rarely Often Usually Always

     6. Drug use
Never Rarely Often Usually Always

     7. Impatience, intolerance, irritability
Never Rarely Often Usually Always

     8. Fatigue
Never Rarely Often Usually Always

     9. Muddled thinking
Never Rarely Often Usually Always

     10. Loss of interest in food
Never Rarely Often Usually Always

     11. Memory problems
Never Rarely Often Usually Always

     12. Migraine headaches
Never Rarely Often Usually Always

     13. Mood disorders
Never Rarely Often Usually Always

     14. Motion sickness
Never Rarely Often Usually Always

     15. Muscle twitches
Never Rarely Often Usually Always

     16. Nervousness
Never Rarely Often Usually Always

     17. Nightmares
Never Rarely Often Usually Always

     18. Night terrors
Never Rarely Often Usually Always

     19. Panic attacks
Never Rarely Often Usually Always

     20. Spasms
Never Rarely Often Usually Always

     21. Stress
Never Rarely Often Usually Always

     22. Anorexia
No Yes

     23. Bulimia
No Yes

     24. Carpal tunnel syndrome
No Yes

     25. Meningitis, Ever had
No Yes

     26. Multiple sclerosis
No Yes

     27. Phobias, Have
No Yes

Section 11. Blood and Cardiovascular System

     1. Blood poisoning
Never Rarely Often Usually Always

     2. Irregular heartbeats
Never Rarely Often Usually Always

     3. Phlebitis
Never Rarely Often Usually Always

     4. Prolonged clotting time
No Yes

     5. Pulse raises after meals
Never Rarely Often Usually Always

     6. Pulse raises for no reason
Never Rarely Often Usually Always

     7. Angina (Chest pains)
Never Rarely Often Usually Always

     8. Varicose veins
None Mild Moderate Severe

     9. Anemia
No Yes

     10. Arteriosclerosis
No Yes

     11. Bleed too long when cut
No Yes

     12. Dropsy
No Yes

     13. Get dizzy if stand up too fast
No Yes

     14. High blood pressure
No Yes

     15. What is your blood pressure?

     16. High cholesterol
No Yes

     17. What is your cholesterol level?

     18. Low blood pressure
No Yes

     19. Mitral valve prolapse
No Yes

     20. Spleen removed
No Yes

     21. Strokes
No Yes

     22. Swollen ankles
No Yes

Section 12. Lungs

     1. Asthma
None Mild Moderate Severe

     2. Bronchitis
Never Rarely Often Usually Always

     3. Cough up blood
Never Rarely Often Usually Always

     4. Cough up phlegm (thick mucus)
Never Rarely Often Usually Always

     5. Dry hacking cough (non-productive)
Never Rarely Often Usually Always

     6. Emphysema
None Mild Moderate Severe

     7. Pneumonia
Never Rarely Often Usually Always

     8. Heavy breather (Must work to breathe)
No Yes

     9. Sigh or yawn often
No Yes

Disclaimer. This form is not used for diagnosis.
The responses you give are used to correlate possible
nutritional deficiencies as suggested by your symptoms in
the Symptom Survey with possible contributing factors
found in the Lifestyle Analysis as suggested by your input
in the Lifestyle Analysis and as correlated with research.
Probable causes will be reported to you along with
strategies or substitutions and/or what
'I or others have or would have done in similar situations'

This document and the responses to it are for educational
purposes only and the choice and responsibility of what you
do remains yours and yours alone.
This is not medical advice and is no substitute for the
services of a medical doctor.

I accept this disclaimer and the personal responsibility it represents. Yes  (Required)
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