Do you currently have any of these problems? |
Yes or No |
If Yes, please describe |
*GENERAL: Fever, weight loss, weight gain,
fatigue? |
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*EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry
Mouth / Throat |
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*CARDIOVASCULAR: High BP, Heart Surgery, Vascular
Disease |
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*RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD |
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*GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent
Urination, impotence |
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*MUSCLES, BONES, JOINTS: Athritis, Joint Pains,
Head or Neck Injury |
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*SKIN: growths, rashes, acne |
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*NEUROLOGICAL: Headaches, migraines, seizures |
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*PSYCHIATRIC: Depression, Anxiety, Insomnia |
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*ENDOCRINE: Thyroid, Diabetes |
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*BLOOD/LYMPH: Anemia, cholesterol, bleeding
problems |
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*ALLERGIC / IMMUNOLOGIC: Seasonal Allergies,
Rheumatoid, AIDS, Allergy Shots, Lupus |
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*GASTROINTESTINAL: Diarrhea, Constipation, Ulcer,
Reflux |
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*SPECIAL NEEDS: Autistic, Non-Verbal, Tactile Sensitivity, Hearing Impaired, Limited Mobility
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