General Questionnaire Date MM DD YYYY Contact Information Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Rate each of the following symptoms based on your typical health profile for the past month. Point Scale: 0 - Never or almost never have the symptom 1 - Occasionally have it, effect is not severe 2 - Occasionally have it, effect is severe 3 - Frequently have it, effect is not severe 4 - Frequently have it, effect is severe HEAD Headaches Faintness Dizziness Insomnia Head Total EYES Watery or itchy eyes Swollen, reddened, or sticky eyelids Bags or dark circles under the eyes Blurred or tunnel vision Eyes Total EARS Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation Ears Total MOUTH/THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums, lips Canker sores Mouth/Throat Total SKIN Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating Skin Total HEART Chest pain Irregular or skipped heartbeat Rapid or pounding heartbeat Heart Total LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing Lungs Total DIGESTIVE TRACT Nausea, vomiting Diarrhea Constipation Belching, passing gas Heartburn Intestinal/stomach pain Digestive Tract Total JOINTS/MUSCLE Pain or aches in joints Arthritis Stiffness or limitation of movement Feeling of weakness or tiredness Pain or aches in muscles Joints/Muscle Total WEIGHT Binge eating/drinking Craving certain foods Excessive weight Water retention Underweight Compulsive eating Weight Total ENERGY/ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness Energy/Activity Total MIND Poor memory Confusion, poor comprehension Difficulty making decisions Stuttering or stammering Slurred speech Learning disabilities Poor concentration Poor physical coordination Mind Total EMOTIONS Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression Emotions Total OTHER Frequent illness Frequent or urgent urination Genital itch or discharge Other Total QUESTIONNAIRE Are you taking any prescription drugs, and if so, how many? Are you currently taking one or more of the following over-the-counter drugs? Cimetidine Acetaminophen Estradiol If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them: Experience side effects, drug(s) is (are) efficacious at a lowered dose(s) Experience side effects, drug(s) is (are) efficacious at usual dose(s) Experience no side effects, drug(s) is (are) usually not efficacious Experience no side effects, drug(s) is (are) usually efficacious Do you currently use or within the last 6 months have you regularly used tobacco products? Do you have strong negative reactions to caffeine or caffeine-containing products? Do you commonly experience “brain fog,” fatigue, or drowsiness? Do you develop symptoms of exposure to fragrances, exhaust fumes, or strong odors? Do you feel ill after you consume even small amounts of alcohol? Do you have a personal history of: Environmental and/or chemical sensitivities Chronic fatigue syndrome Multiple chemical sensitivity Fibromyalgia Parkinson’s type symptoms Alcohol or chemical dependence Asthma Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents? Do you have an adverse or allergic reaction when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc? Do you have a history or currently have kidney dysfunction? Are you currently on diuretics or blood pressure medication? Have you ever been diagnosed with a condition known as hyperkalemia? Thank you! I will be in touch soon.