Health Survey
Have you experienced any of the following symptoms within the past year?
Weight/Other
YesNo
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Digestive Tract
YesNo
Nausea or vomiting
Diarrhea
Constipation
Bloated feeling
Belching, or passing gas
Heartburn
Heart/Lungs
YesNo
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Chest congestion
Asthma, bronchitis
Shortness of breath
Ears/Mouth/Throat/Nose/Eyes
YesNo
Itchy ears
Earaches, ear infections
Ringing in ears, hearing loss
Drainage from ear
Stuffy nose
Sinus problems
Hay fever
Excessive mucus formation, post-nasal drip
Sneezing attacks
Poor night vision
Watery or itchy eyes
Swollen, tender or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Chronic coughing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Joints/Muscles/Skin
YesNo
Pain or aches in joints
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Cramps in legs
Acne
Hives, rashes, or dry skin
Hair loss
Flushing or hot flashes
Fingernail abnormalities (spots, ridges)
Decreased sweating
Night sweats
Energy/Activity
YesNo
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Easy fatiguability or lack of endurance
Headaches
Faintness
Dizziness
Insomnia
Emotional/Mental
YesNo
Mood swings
Anxiety, fear or nervousness
Anger or irritability
Depression
Poor memory
Confusion, poor comprehension
Poor concentration
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities