Choose the best response for each question and complete all sections.
Your name and your responses will be strictly confidential.

Pressing clear before you begin resets all answers to: "None," "Never" and "No."
You need only respond when your answers are one of the other choices.
"Never" is once a year or less.
"Rarely" is once a month or less.
"Often" is more than once a month.
"Usually" is once a week or more.
"Always" is several times a week or more.

Section 13. Hair

     1. Balding
No Yes

     2. Hair is brittle or breaks off
No Yes

     3. Dry hair
No Yes

     4. Dull hair
No Yes

     5. Hair falls out too fast
No Yes

     6. Hair is graying early
No Yes

     7. Hair is greasy
No Yes

     8. Hair grows slowly
No Yes

     9. Itchy scalp
No Yes

     10. Oily hair
No Yes

     11. Seborrhea
No Yes

     12. Thinning hair
No Yes

     13. Dandruff
None Mild Moderate Severe

Section 14. Skin

     1. Age spots
None Mild Moderate Severe

     2. Bluish color to skin
No Yes

     3. Boils, get often
No Yes

     4. Bruise easily
No Yes

     5. Carbuncles, get often
No Yes

     6. Cellulite
None Mild Moderate Severe

     7. Does not sweat
No Yes

     8. Dry skin
No Yes

     9. Eczema
No Yes

     10. Flushes easily
No Yes

     11. Hives, get often
No Yes

     12. Impetigo, (skin infection with pimples) get often
No Yes

     13. Itching often
No Yes

     14. Oily skin
No Yes

     15. Pimples, Get
No Yes

     16. Psoriasis
No Yes

     17. Ringworm
No Yes

     18. Shingles
No Yes

     19. Skin peels after sunburn
No Yes

     20. Sunburn easily
No Yes

     21. Sweat at night
No Yes

     22. Sweat too much in general
No Yes

     23. Warts
None Mild Moderate Severe

     24. Yellowish cast to skin
No Yes

     25. Flea and mosquito bites (Seasonally)
None Mild Moderate Severe

     26. Permanent goose-pimple like bumps on legs and/or arms,
maybe cheeks, might be red but are not infected.
No Yes

Section 15. Nails

     1. Bluish colored nails
No Yes

     2. Nails break easily
No Yes

     3. Discolored nails
No Yes

     4. Hangnails
No Yes

     5. Have fungus infections of finger or toe nails
No Yes

     6. Nails are ridged crosswise
No Yes

     7. Nails are ridged lengthwise
No Yes

     8. Nails are slow growing
No Yes

     9. Nails are weak
No Yes

     10. Nails have white spots in them
None Mild Moderate Severe

     11. Nails peel apart
No Yes

     12. Thickened toenails
No Yes

Section 16. Musculoskeletal System

     1. Aching muscles
Never Rarely Often Usually Always

     2. Arthritis
(If have either or both types, check "Yes", then indicate details below.)
No Yes
Osteoarthritis
Mild Moderate Severe

Rheumatoid arthritis
Mild Moderate Severe

     3. Charley horses at night "Calf cramps"
None Mild Moderate Severe

     4. Cracking or popping joints
None Mild Moderate Severe

     5. Fibromyalgia
None Mild Moderate Severe

     6. Joint pains
None Mild Moderate Severe

     7. Low back pain
Never Rarely Often Usually Always

     8. Muscle cramps while exercising
Never Rarely Often Usually Always

     9. Muscle spasms
Never Rarely Often Usually Always

     10. Neck pain, (Tight muscles)
Never Rarely Often Usually Always

     11. Osteoporosis
None Mild Moderate Severe

     12. Pain between shoulder blades (Muscle tension)
None Mild Moderate Severe

     13. Easily broken bones
No Yes

     14. Get sprains easily
No Yes

     15. Stiff muscles
No Yes

     16. Trembling
No Yes

Section 17. Feet

     1. Aching feet
No Yes

     2. Athlete's foot
No Yes

     3. Badly smelling shoes
No Yes

     4. Bunions
No Yes

     5. Burning feet
No Yes

     6. Corns
No Yes

     7. Fungus toenails
No Yes

     8. Heel spurs
No Yes

     9. Plantar warts
No Yes

     10. Smelly feet
No Yes

     11. Smelly socks after only one day
No Yes

     12. Thick dry callouses on feet; esp. heels, may be cracked
No Yes

     13. Tired feet
No Yes

Section 18. Immune System

     1. Allergies
Never Rarely Often Usually Always

     2. Get colds easily or often
Never Rarely Often Usually Always

     3. Get the flu easily or often
Never Rarely Often Usually Always

     4. Have fevers
Never Rarely Often Usually Always

     5. Have nausea often
Never Rarely Often Usually Always

     6. Have prickly heat
Never Rarely Often Usually Always

     7. Hay fever
No Yes

     8. Hemodialysis
No Yes

     9. Hypoglycemia
No Yes

     10. Infections easily acquired
No Yes

     11. Intestinal diseases
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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