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Step 1  - Health Symptom Questionnaire

Please do not complete this if you are not doing the
BodyTerrain Test or the Wellness Chemistry Panel. 
This questionnaire can be completed for free at www.Holistic-Physician.com

Required Information: 

Name:   

eMail address

Instructions: Please Rate each of the following symptoms based on your typical health profile for the past 30 days.

Point Scale: 0 - Never or almost never have the symptoms  
  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  
EYES Watery or Itchy eyes  
  Swollen, reddened or sticky eyelids  
  Bags or dark circles under eyes  
  Blurred or tunnel vision (does not include near or far sightedness)  
EARS Itchy ears  
  Earaches, ear infections  
  Drainage from ear  
  Ringing in ears, hearing loss  
NOSE Stuffy nose  
  Sinus problems  
  Hay fever  
  Sneezing attacks  
  Excessive mucus formation  
MOUTH/THROAT Chronic coughing  
  Gagging, frequent need to clear throat  
  Sore throat, hoarseness, loss of voice  
  Swollen or discolored tongue, gums, lips  
  Canker sores  
SKIN Acne  
  Hives, rashes, dry skin  
  Hair loss  
  Flushing, hot flashes  
  Excessive sweating  
HEART Irregular or skipped heartbeat  
  Rapid or pounding heartbeat  
  Chest pain  
LUNGS Chest congestion  
  Asthma, bronchitis  
  Shortness of breath  
  Difficulty breathing  
DIGESTIVE TRACT Nausea, vomiting  
  Diarrhea  
  Constipation  
  Bloated feeling  
  Belching, passing gas  
  Heartburn  
  Intestinal, stomach pain  
JOINTS MUSCLE Pain or aches in joints  
  Arthritis  
  Stiffness or limitation of movement  
  Pain or aches in muscles  
  Feeling of weakness or tiredness  
WEIGHT Binge eating/drinking  
  Craving certain foods  
  Excessive weight  
  Compulsive eating  
  Water retention  
  Underweight  
ENERGY/ACTIVITY Fatigue, sluggishness  
  Apathy, lethargy  
  Hyperactivity  
  Restlessness  
MIND Poor Memory  
  Confusion, poor comprehension  
  Poor concentration  
  Poor physical coordination  
  Difficulty in making decisions  
  Stuttering or stammering  
  Slurred speech  
  Learning disabilities  
EMOTIONS Mood swings  
  anxiety, fear, nervousness  
  Anger, Irritability, aggressiveness  
  Depression  
OTHER Frequent illness  
  Frequent or urgent urination  
  Genital itch or discharge  

PLEASE PRINT this questionnaire before you submit and SAVE your paper copy.  Electronic data always has a potential to get lost.  By printing this information, you will protect yourself against data loss and the need to unnecessarily have to re-take the questionnaire.

 
 

The information contained in this website is for informational and educational purposes only. No statement should be considered medical advice or be used to diagnose or treat any illnesses or diseases. Before undertaking any health regimen, please consult with your own health care provider. Only a licensed health professional can diagnose and treat disease.  Please use this and all health related information responsibly.

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