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Current Symptoms Questionnaire Part 1

FIRST & LAST NAME

EMAIL

Please check the grey circle for all that apply to you:

Syncope (feeling faint)

Bilateral neck throbbing around lymph nodes

Elevated thyroid

Anemia

Feeling of burning skin

Bones ache in extremities

Phantom smells

"Hot" blood rush

Chills but not fever

Herpes, EBV or trigeminal neuralgia

Drastic personality change

GERD with excessive salivation

Thrush

Hormone imbalances

Neck muscle pain

Mouth sores or sore tongue

Heat intolerance

Swollen hands or feet

Dry or peeling skin

Urinary tract infection

Kidney issues or protein inurine

Dry scalp or dandruff

Low blood pressure

COVID toes

Eye stye or infection

High blood pressure

Dry throat

Post nasal drip

Weight loss

Feeling irritable

Foot pain

Goiter or lump in throat

Cracked or dry lips

Cold buring feeling in lungs

Low bloodoxygen

Muscle twitching

Confusion

Sharp or sudden chest pain

Change sense of taste

Tinnitus or humming in ears

Arrhythmia

Painful scalp

Jaw pain

Burning sensations

Mid-back pain at base of ribs

Nerve sensations

Constant thirst

Rash

Floaters or flashes of light in vision

Abnormally low temperature

Upper back pain

Bulging veins

Hand or wrist pain

Costochondritis (inflammation ofribs and stenum area)

Spikes in bood pressure

Sleeping more than normal

Tremors or shakiness

Calf cramps

Dry eyes

Clogged ears

Kidney pain

Brain pressure

Swollen lymph nodes

Extreme pressure at base of head or occipital nerve

Phlegm in back of throat

Weight gain

Nausea or vomiting

Shortness of breath or exhaustion from bending over

Lower back pain

Abdominal pain

We got it! Move on to PART 2

Part 2

FIRST & LAST NAME

EMAIL

Please check the grey circle for all that apply to you:

Partial or complete loss of sense of smell

Changing symptoms

Reflux or heartburn

Neuropathyin feet and hands

Sadness

Congested or runny nose

Blurry vision

Hair loss

Fever or chills

Tachycardia

Partial or complete loss of sense of smell

Night sweats

Sore throat

Diarrhea

Heart palitations

Joint pain

Cough

Persistent chest pain or pressure

Dizziness

Memory problems

Anxiety

Difficulty sleeping

Headache

Inability to exercise or be active

Difficulty concentrating or focusing

Shortness of breath or difficulty breathing

Muscle or body aches

Fatigue

You're Done! Thank you!

We are here to help! 678.242.0204

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