NUTRITION INTAKE HISTORY

Date Patient Information

Patient Address Apt.

Age Sex: M F City State Zip

Home # Work # Ext. Birthdate Cell Phone # Patient SS# E-Mail Single Married Separated Divorced Widowed Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT Name Relationship Home Phone Work Phone Ext.

Whom may we thank for referring you?

Work Information

Occupation Phone Ext. Company Address

Spouse Information

Name SS# Birthdate Occupation Employer

I verify that all information within these pages is true and accurate.

______Patient's Signature Patient's Name - Please print Date Health History

Height Weight Number of Children Are you recovering from a cold or flu? Are you pregnant? Reason for office visit: Date started:

Date of last physical exam Practitioner name & contact Laboratory procedures performed (e.g., stool analysis, blood and urine chemistries, hair analysis, saliva, bone density):

Outcome What types of therapy have you tried for this problem(s)? Diet modification Medical Vitamins/minerals Herbs Homeopathy Chiropractic

Acupunture Conventional drugs Physical therapy Other List current health problems for which you are being treated: Current medications (prescription and/or over-the-counter):

Major hospitalizations, surgeries, injuries. Please list all procedures, complications (if any) and dates: Year Surgery, illness, injury Outcome

Circle the level of stress you are experiencing on a scale of 1 to 10 (1 being the lowest): 1 2 3 4 5 6 7 8 9 10 Identify the major causes of stress (e.g., job change, family status change, work related, finances, etc..) Do you consider yourself: Underweight Overweight Just right Your weight now: Have you had an unintentional weight loss or gain of 10 pounds or more in the last 3 months? Yes No Is your job associated with potentially harmful chemicals (e.g., pesticides, radioactivity, solvents) or health and/or life threatening activities (.e.g, fireman, farmer, miner)?

Corrective lenses Dentures Hearing aid Medical devices/prothetics/implants, describe:

Recent changes in your ability to: See Hear Taste Smell Feel hot/cold sensations

Move around (sit upright, stand, walk, run, pick up things, swing your arms freely, turn your head, wiggle fingers)

Strong like for any of the following flavors: Sour Bitter Sweet Rich/Fatty Spicy/Pungent

Salty

Strong dislike for any of the following flavors: Sour Bitter Sweet Rich/Fatty Spicy/Pungent

Salty Do you: Prefer warmth (i.e. foods, drinks, weather, ect…) Prefer cold (i.e. foods, drinks, weather, ect…) N/A Is your sleep disturbed at the same time each night? If yes, what time? Time of day you feel the most energy or the least symptoms: Time of day you feel the worst or your symptoms are aggravated: 6:00 am - 12:00 pm 6:00 pm - 12:00 am 6:00 am - 12:00 pm 6:00 pm - 12:00 am

12:00 pm - 6:00 pm 12:00 am - 6:00 am 12:00 pm - 6:00 pm 12:00 am - 6:00 am

Do you experience any of these general symptoms EVERYDAY?

Shortness of breath Nausea Fecal incontinence Bleeding Insomnia

Headaches Vomiting Urinary incontinence Discharge Constipation

Dizziness Diarrhea Low grade fever Itching/rash Chronic pain/inflammation Medical History Health Habits Current Supplements

Arthritis Decreased sex drive Tobacco: # per day ______Multivitamin/mineral

Allergies/hay fever Infertility Alcohol: Vitamin C

Asthma Sexually transmitted disease Wine: # glasses/d or wk ______Vitamin E

Alcoholism Other ______Liquor: #oz./d or wk ______EPA/DHA Alzheimer's disease Medical (Women) Beer: # glasses/d or wk ______Evening primrose/GLA Autoimmune disease Menstrual irregularities Caffeine: Calcium, source ______

Blood pressure problems Endometriosis Coffee: # 6oz. Cup/day ______Magnesium

Bronchitis Infertility Tea: # 6oz. Cup/day ______Zinc

Cancer Fibrocystic breasts Soda: # cans/day ______Minerals, describe ______

Chronic fatigue syndrome Fibroids/ovarian cysts Other ______Friendly flora (acidophilus)

Carpal tunnel syndrome Premenstrual syndrome (PMS) Water: # glasses/day ______Digestive enzymes

Cholesterol - elevated Breast cancer Amino acids Circulatory problems Pelvic inflammatory disease Exercise CoQ10 Colitis Vaginal infections 5 - 7 days per week Antioxidants (eg, lutein, resveratrol, etc.)

Dental problems Decreased sex drive 3 - 4 days per week Herbs - teas

Depression Sexually transmitted disease 1 - 2 days per week Herbs - extracts

Diabetes Other ______45 min or more duration/wk Chinese herbs

Diverticular disease Age of first period ______30 - 45 min duration/workout Ayurvedic herbs

Drug addiction Date of last gynecological exam ______Less than 30 min Homeopathy

Eating disorder Mammogram + - Walk Bach flowers

Epilepsy PAP + - Run, Jog, jump rope Protein shakes

Emphysema Form of birth control ______Weight-lift Superfoods (eg. Phytonutrient blends)

Eyes, ears, nose, throat problems # of children ______Swim Liquid meals

Environmental sensitivities # of pregnancies ______Box Other______

Fibromyalgia C-section ______Yoga

Food intolerance Surgical menopause Other ______Would you like to: Gastroesophageal reflux disease Menopause Nutrition & Diet Have more energy Genetic disorder Date of last menstrual cycle ______Mixed food diet (animal & veg) Be stronger

Glaucoma Length of cycle ______days Vegetarian Have more endurance

Gout Interval between cycles ______days Vegan Increase your sex drive

Heart disease Recent changes in normal menstrual flow Salt restriction Be thinner (e.g., heavier, large clots, scanty) ______Inflammatory bowel disease Fat restriction Be more muscular Irritable bowel syndrome Family Healthy Starch/carbohydrate restriction Improve your complexion Kidney or bladder disease History Total calorie restriction Have stronger nails Learning disabilities Arthritis Specific food restrictions: ______Have healthier hair

Liver or gallbladder disease (stones) Astma ______Be less moody

Mental illness Alcoholism Other ______Be less depressed

Migraine headaches Alzheimer's disease Feel more motivated Neurological problems Cancer Food Frequency Be more organized (Parkinson's, paralysis) Servings per day: Sinus problems Depression Fruits (citrus, melons, etc.) ______Thisnk more clearly; be more focused

Stroke Diabetes Dark green or deep yellow/orange Improve memory

Thyroid trouble Drug addiction vegetables ______Do better on tests

Obesity Glaucoma Grains (unprocessed) ______Not be dependent on over-the-counter meds like aspirin, ibuprofen, sleeping aids, etc Osteoporosis Heart disease Beans, peas, legumes ______Stop using laxatives or stool softeners

Pneumonia Infertility Dairy, eggs ______Be free of pain

Sexually transmitted disease Learning disabilities Meat, poultry, fish ______Sleep better

Seasonal affective disorder Mental illness Have agreeable breath

Skin problems Mental retardation Eating Habits Have agreeable body odor Tuberculosis Migraine headaches Skip breakfast Have stronger teeth

Ulcer Neurological disorders Two meals/day Get less colds and flus (Parkinson's, paralysis) Urinary tract infection Obesity One meal/day Get rid of your allergies

Varicose veins Osteoporosis Graze (small frequent meals) Reduce your risk of inherited disease tendencies (eg. cancer, heart disease, etc..) Other ______Stroke Food rotation

Suicide Eat constantly (hungry or not) Medical (Men) Benign prostatic hyperplasia (BPH) Other ______Eat on the run

Prostate cancer ______Add salt to food Systems Survey Form | Restricted to Professional Use WHOLE FOOD NUTRIENT SOLUTIONS

name: DATE OF BIRTH: EMAIL:______date:

INSTRUCTIONS: Circle the number that applies to you. If a symptom does not apply, don’t circle anything for that symptom.

Circle the corresponding number. 1 MILD symptom (occurs rarely) 2 MODERATE symptom (occurs several times a month) 3 SEVERE symptom (occurs almost constantly)

GROUP 1 45. 1 2 3 Get “shaky” if hungry 85. 1 2 3 Discomfort between 1. 1 2 3 Acid foods upset 46. 1 2 3 Fatigue, eating relieves shoulder blades 2. 1 2 3 Get chilled often 47. 1 2 3 “Lightheaded” if meals delayed 86. 1 2 3 Occasional laxative use 3. 1 2 3 “Lump” in throat 48. 1 2 3 Heart palpitates if meals missed 87. 1 2 3 Stools alternate from soft 4. 1 2 3 Dry mouth, eyes, nose or delayed to watery 5. 1 2 3 Pulse speeds after meal 49. 1 2 3 Fatigue in afternoon 88. 1 2 3 Sneezing attacks 6. 1 2 3 Keyed up, fail to calm 50. 1 2 3 Overeating sweets upsets 89. 1 2 3 Dreaming, nightmare-type 7. 1 2 3 Gag occasionally 51. 1 2 3 Awaken after few hours sleep, bad dreams 8. 1 2 3 Unable to relax, startle easily hard to get back to sleep 90. 1 2 3 Bad breath (halitosis) 9. 1 2 3 Extremities cold, clammy 52. 1 2 3 Crave candy or coffee in afternoon 91. 1 2 3 Milk products cause upset 10. 1 2 3 Strong light irritates 53. 1 2 3 Moods of “blues” or melancholy 92. 1 2 3 Sensitive to hot weather 11. 1 2 3 Occasionally weak urine flow 54. 1 2 3 Craving for sweets or snacks 93. 1 2 3 Burning or itching anus 12. 1 2 3 Heart pounds after retiring 94. 1 2 3 Crave sweets TOTAL 13. 1 2 3 “Nervous” stomach 1 2 3 TOTAL 14. 1 2 3 Appetite reduced occasionally 1 2 3 15. 1 2 3 Cold sweats often GROUP 4 16. 1 2 3 Get heated easily 55. 1 2 3 Hands and feet go to GROUP 6 17. 1 2 3 Nerve discomfort sleep easily, numbness 95. 1 2 3 Loss of taste for meat 18. 1 2 3 Staring, blink little 56. 1 2 3 Sigh frequently, “air hunger” 96. 1 2 3 Lower bowel gas several hours 19. 1 2 3 Sour stomach frequent 57. 1 2 3 Aware of “breathing heavily” after eating 58. 1 2 3 High-altitude discomfort 97. 1 2 3 Burning stomach sensations, TOTAL 1 2 3 59. 1 2 3 Open windows in closed room eating relieves 60. 1 2 3 Immune system challenges 98. 1 2 3 Coated tongue GROUP 2 61. 1 2 3 Afternoon “yawner” 99. 1 2 3 Pass large amounts 20. 1 2 3 Joint stiffness after arising 62. 1 2 3 Get “drowsy” often of foul-smelling gas

21. 1 2 3 Muscle, leg, toe cramps at night 63. 1 2 3 Swollen ankles worse at night 100. 1 2 3 Indigestion ⅟2 -1 hour after eating; 22. 1 2 3 “Butterfly” stomach, cramps 64. 1 2 3 Muscle cramps, worse during may be up to 3-4 hours after 23. 1 2 3 Eyes or nose watery exercise; get “charley horse” 101. 1 2 3 Watery or loose stool 24. 1 2 3 Eyes blink often 65. 1 2 3 Difficulty catching breath, 102. 1 2 3 Gas shortly after eating 25. 1 2 3 Eyelids swollen, puffy especially during exercise 103. 1 2 3 Stomach “bloating” 26. 1 2 3 Indigestion soon after meals 66. 1 2 3 Tightness or pressure in chest, TOTAL 27. 1 2 3 Always seem hungry, worse on exertion 1 2 3 feel “lightheaded” often 67. 1 2 3 Skin discolors easily after impact 28. 1 2 3 Digestion rapid 68. 1 2 3 Tendency to anemia GROUP 7A 29. 1 2 3 Vomit occasionally 69. 1 2 3 Noises in head or “ringing in ears” 104. 1 2 3 Difficulty sleeping 30. 1 2 3 Hoarseness frequent 70. 1 2 3 Fatigue upon exertion 105. 1 2 3 On edge 31. 1 2 3 Uneven breathing 106. 1 2 3 Can’t gain weight TOTAL 32. 1 2 3 Pulse slow 1 2 3 107. 1 2 3 Intolerance to heat 33. 1 2 3 Gagging reflex slow 108. 1 2 3 Highly emotional 34. 1 2 3 Difficulty swallowing GROUP 5 109. 1 2 3 Flush easily 35. 1 2 3 Temporary constipation or diarrhea 71. 1 2 3 Dizziness 110. 1 2 3 Night sweats 36. 1 2 3 “Slow starter” 72. 1 2 3 Dry skin 111. 1 2 3 Thin, moist skin 37. 1 2 3 Get “chilled” 73. 1 2 3 Burning feet 112. 1 2 3 Inward trembling 38. 1 2 3 Perspire easily 74. 1 2 3 Blurred vision 113. 1 2 3 Heart races 39. 1 2 3 Sensitive to cold 75. 1 2 3 Itching skin and feet 114. 1 2 3 Increased appetite without 40. 1 2 3 Upper respiratory challenges 76. 1 2 3 Hair loss weight gain 77. 1 2 3 Occasional skin rashes 115. 1 2 3 Pulse fast at rest TOTAL 1 2 3 78. 1 2 3 Bitter, metallic taste in mouth 116. 1 2 3 Eyelids and face twitch in morning 117. 1 2 3 Irritable and restless GROUP 3 79. 1 2 3 Occasional constipation 118. 1 2 3 Can’t work under pressure 41. 1 2 3 Eat when nervous 80. 1 2 3 Worrier, feels insecure TOTAL 42. 1 2 3 Excessive appetite 81. 1 2 3 Nausea occasionally after eating 1 2 3 43. 1 2 3 Hungry between meals 82. 1 2 3 Greasy foods upset 44. 1 2 3 Irritable before meals 83. 1 2 3 Stools light-colored 84. 1 2 3 Skin peels on foot soles GROUP 7B GROUP 7F 119. 1 2 3 Increase in weight 151. 1 2 3 Weakness, dizziness 187. 1 2 3 Nervousness causing 120. 1 2 3 Decrease in appetite 152. 1 2 3 Tired throughout day loss of appetite 121. 1 2 3 Fatigue easily 153. 1 2 3 Nails weak, ridged 188. 1 2 3 Nervousness with indigestion 122. 1 2 3 Ringing in ears 154. 1 2 3 Sensitive skin 189. 1 2 3 Gastritis 123. 1 2 3 Sleepy during day 155. 1 2 3 Stiff joints 190. 1 2 3 Forgetfulness 124. 1 2 3 Sensitive to cold 156. 1 2 3 Perspiration increase 191. 1 2 3 Thinning hair 125. 1 2 3 Dry or scaly skin 157. 1 2 3 Bowel discomfort TOTAL 126. 1 2 3 Temporary constipation 158. 1 2 3 Poor circulation 1 2 3 127. 1 2 3 Mental sluggishness 159. 1 2 3 Swollen ankles 128. 1 2 3 Hair coarse, falls out 160. 1 2 3 Crave salt FEMALE ONLY 129. 1 2 3 Tension in head upon arising 161. 1 2 3 Areas of skin darkening 192. 1 2 3 Very easily fatigued wears off during day 162. 1 2 3 Upper respiratory sensitivity 193. 1 2 3 Premenstrual tension 130. 1 2 3 Slow pulse below 65 163. 1 2 3 Tiredness 194. 1 2 3 Menses more painful than usual 131. 1 2 3 Changing urinary function 164. 1 2 3 Breathing challenges 195. 1 2 3 Depressed feelings 132. 1 2 3 Sounds appear diminished before menstruation TOTAL 133. 1 2 3 Reduced initiative 1 2 3 196. 1 2 3 Painful breasts during menses

TOTAL 197. 1 2 3 Menstruate too frequently 1 2 3 GROUP 8 198. 1 2 3 Hysterectomy/ovaries removed GROUP 7C 165. 1 2 3 Muscle weakness 199. 1 2 3 Menopausal hot flashes 134. 1 2 3 Failing memory with age 166. 1 2 3 Lack of stamina 200. 1 2 3 Menses scanty or missed 135. 1 2 3 Increased sex drive 167. 1 2 3 Drowsiness after eating 201. 1 2 3 Acne, worse at menses 136. 1 2 3 Episodes of tension in head 168. 1 2 3 Muscular soreness TOTAL 137. 1 2 3 Decreased sugar tolerance 169. 1 2 3 Heart races 1 2 3

TOTAL 170. 1 2 3 Hyperirritable 1 2 3 171. 1 2 3 Feeling of a band around head MALE ONLY GROUP 7D 172. 1 2 3 Melancholia (feeling of sadness) 202. 1 2 3 Less involved in 138. 1 2 3 Abnormal thirst 173. 1 2 3 Swelling of ankles exercise/social activities 139. 1 2 3 Bloating of abdomen 174. 1 2 3 Change in urinary function 203. 1 2 3 Difficult to postpone urination 140. 1 2 3 Weight gain around hips or waist 175. 1 2 3 Tendency to consume 204. 1 2 3 Weak urinary stream 141. 1 2 3 Sex drive reduced or lacking sweets/carbohydrates 205. 1 2 3 Feeling of “blues” or melancholy 142. 1 2 3 Tendency for stomach issues 176. 1 2 3 Muscle spasms 206. 1 2 3 Feeling of incomplete 143. 1 2 3 Immune system challenges 177. 1 2 3 Blurred vision bowel evacuation 144. 1 2 3 Menstrual disorders 178. 1 2 3 Involuntary muscle action 207. 1 2 3 Lack of energy

TOTAL 179. 1 2 3 Numbness 208. 1 2 3 Muscles in arms and legs seem 1 2 3 180. 1 2 3 Night sweats softer/smaller GROUP 7E 181. 1 2 3 Rapid digestion 209. 1 2 3 Tire too easily 145. 1 2 3 Dizziness 182. 1 2 3 Sensitivity to noise 210. 1 2 3 Avoid activity 146. 1 2 3 Headaches 183. 1 2 3 Redness of palms of hands and 211. 1 2 3 Leg nervousness at night 147. 1 2 3 Hot flashes bottom of feet 212. 1 2 3 Diminished sex drive 148. 1 2 3 Hair growth on face 184. 1 2 3 Visible veins on chest and abdomen TOTAL or body (female) 185. 1 2 3 Hemorrhoids 1 2 3 149. 1 2 3 Sugar in urine (not diabetes) 186. 1 2 3 Apprehension (feeling that 150. 1 2 3 Masculine tendencies (female) something bad is going to happen)

TOTAL 1 2 3

IMPORTANT | Please list below the five main physical complaints you have in order of their importance.

1.

2.

3.

4.______

5.______

ADDITIONAL COMMENTS:

HEALTH PROFILE

NAME ______DATE ______E-MAIL ______

Rate each of the following symptoms based upon your typical health profile for: Past 30 days Past 48 hours 0 Never or almost never have the symptom 3 Frequently have it, effect is not severe Point 1 Occasionally have it, effect is not severe 4 Frequently have it, effect severe Scale 2 Ocassionally have it, effect is severe

HEAD Headaches DIGESTIVE Nausea, vomitting Faintness TRACT Diarrhea Dizziness Constipation Insomnia Cbloated feeling TOTAL Belching, passing gas Heartburn EYES Watery or itchy eyes Intestinal/stomach pain Swollen, reddened or sticky eyelids TOTAL Bags or dark circles under eyes Blurred or tunnel vision JOINTS/ Pain or aches in joints (does not include near- or far-sightedness) MUSCLE Arthritis TOTAL Stiffness or limitation of movement Pain or aches in muscles NOSE Stuffy nose Feeling of weakness or tiredness Sinus problems TOTAL Hay fever Sneezing attacks WEIGHT Binge eating/drinking Excessive mucus formation Craving certain foods TOTAL Excessive weight Compulsive eating MOUTH/ Chronic coughing Water retention THROAT Gagging, frequent need to clear throat Underweight Sore throat, hoarseness, loss of voice TOTAL Swollen or discolored tongue, gums or lips ENERGY/ Fatigue, sluggishness Canker sores ACTIVITY Apathy, lethargy TOTAL Hyperactivity Restlessness SKIN Acne TOTAL Hives, rashes, dry skin Hair loss MIND Poor memory Flushing, hot flashes Confusion, poor comprehension Excessive sweating Poor concentration TOTAL Poor physical coordination Difficulty in making decisions HEART Irregular or skipped heartbeat Stuttering or stammering Rapid or pounding heartbeat Slurred speech Chest pain Learning disabilities TOTAL TOTAL

LUNGS Chest congestion EMOTIONS Mood swings Asthma, bronchitis Anxiety, fear, nervousness Shortness of breath Anger, irritability, aggressiveness Difficulty breathing Depression TOTAL TOTAL

OTHER Frequent illness Frequent or urgent urination Genital itch or discharge TOTAL

GRAND TOTAL NAME______EMAIL______DATE______Please rate each of the following based on your health profile based Toxicity Questionnaire on the last 90 days: (0 = Rarely or never experience the symptom 1= Occasionally experience but effective is not severe 2 = Occasionally experience but effect is severe 3 = Frequently experience and effect is not severe 4 = Frequently experience and effect is severe) Digestive: Hormones: Ears, Sinus, Nose: Nausea 01234 OilySkin,Acne 01234 Poppingears 01234 DiarrheaorVomiting 01234 Painduringperiod 01234 Fluidinears 0 1 2 3 4 Heartburn, Reflux 0 1 2 3 4 Breast tenderness 0 1 2 3 4 Ringing ear 0 1 2 3 4 Straining on bowel Mvmt0 1 2 3 4 Irregular cycle 0 1 2 3 4 Hearing loss 0 1 2 3 4 Day without bowel mvmt0 1 2 3 4 Weight gain 0 1 2 3 4 Ear Infections 0 1 2 3 4 Gas,Belch,Bloating 01234 Cryeasily 01234 Excessivemucous 01234 Hemorrhoids 0 1 2 3 4 Vaginal dryness 0 1 2 3 4 Stuffy nose 0 1 2 3 4 Total for section: ______Hot flashes 0 1 2 3 4 Sinus headache 0 1 2 3 4 Heart: Loss of sex drive 0 1 2 3 4 Nose bleeds 0 1 2 3 4 Shortness of Breath 0 1 2 3 4 Erectile dysfunction 0 1 2 3 4 Total for section: ______Skipped, Rapid Heartbeat 01234 Balding 0 1 2 3 4 Mouth, Throat, Teeth: High/Low Blood Pressure 0 1 2 3 4 Anger easily 0 1 2 3 4 Dry Mouth 0 1 2 3 4 Chest Pain 0 1 2 3 4 Totalforsection: ______Canker sores 0 1 2 3 4 Tightness in chest 0 1 2 3 4 Head, Eyes: Cold sores 0 1 2 3 4 Total for section: ______Blurred Vision 0 1 2 3 4 Tooth pain 0 1 2 3 4 Emotions: Pressure 0 1 2 3 4 Bleeding gums 0 1 2 3 4 Mood Swings 0 1 2 3 4 Faintness 01234 Gagging,clearingthroat01234 Anxiety / Fear / Nervous0 1 2 3 4 Dizziness 0 1 2 3 4 Total for section: ______Anger / Irritability 0 1 2 3 4 Headaches 0 1 2 3 4 Lungs: Panic Attacks 0 1 2 3 4 Totalforsection: ______Difficulty breathing 0 1 2 3 4 Depression 0 1 2 3 4 Allergies: Chest congestion 0 1 2 3 4 Sense of Despair 0 1 2 3 4 Watery, Itchy Eyes 0 1 2 3 4 Coughing 0 1 2 3 4 Total for section: ______Runny Nose 01234 Asthma 0 1 2 3 4 Energy: Sneezing 0 1 2 3 4 Total for section: ______Fatigue / Tired 0 1 2 3 4 Itchy throat 0 1 2 3 4 Joints, Muscles, Bones: Sluggishness 0 1 2 3 4 Itchy skin 0 1 2 3 4 Twitching 0 1 2 3 4 Hyperactivity 01234 Postnasaldrip 01234 Cramping 0 1 2 3 4 Restlessness 0 1 2 3 4 Totalforsection: ______Stiff & achy joints 0 1 2 3 4 Brain Fog 0 1 2 3 4 Immune: Pain in joints 0 1 2 3 4 Irritable if miss meals 0 1 2 3 4 Frequent illness 0 1 2 3 4 Swelling in Joints 0 1 2 3 4 Swellinghandsandfeet01234 Sorethroat 0 1 2 3 4 Muscle aches 0 1 2 3 4 Total for section: ______Fever 0 1 2 3 4 Muscle pains 0 1 2 3 4 Skin, Hair, Nails: Genital itch, Discharge 0 1 2 3 4 Osteoporosis 0 1 2 3 4 Flushing 0 1 2 3 4 Yellow nail fungus 0 1 2 3 4 Numbness, Burning 0 1 2 3 4 Cold hands & feet 0 1 2 3 4 Totalforsection: ______Flat feet, Fallen arch 0 1 2 3 4 Acne 0 1 2 3 4 Urinary Tract: Total for section: ______Dry skin /Oily skin 0 1 2 3 4 Frequent urination 0 1 2 3 4 Sleep: Hives, rashes 0 1 2 3 4 Burning on urination 0 1 2 3 4 fall asleep 0 1 2 3 4 Eczema,Psoriasis 01234 Dribblingurine 01234 Wakeupoften 01234 Hair loss 0 1 2 3 4 Leaky bladder 0 1 2 3 4 Nighttime Urination 0 1 2 3 4 Cracked heels on feet 0 1 2 3 4 Blood in urine 0 1 2 3 4 Wake up tired 0 1 2 3 4 Bruising 0 1 2 3 4 Kidney stones 0 1 2 3 4 Bad dreams/Nightmare 0 1 2 3 4 Brittle nails 0 1 2 3 4 Totalforsection: ______Night sweats 0 1 2 3 4 Total for section: ______Total for section: ______

Signature:______Date:______Total For All Sections:______

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