EARS
__ Itchy ears
__ Earaches, ear infection
__ Drainage from ear
__ Ringing in ears hearing loss
__ TOTAL

EMOTIONS
__ Mood swings
__ Anxiety, fear, nervousness
__ Anger, irritability
__ Depression
__ TOTAL

ENERGY/ACTIVITY
__ Fatigue, sluggishness
__ Apathy, lethargy
__ Hyperactivity
__ Restlessness
__ TOTAL

EYES
__ Watery, itchy eyes
__ Swollen, reddened or sticky eyelids
__ Dark circles under eyes
__ Blurred/tunnel vision
__ TOTAL

HEAD
__ Headaches
__ Faintness
__ Dizziness
__ Insomnia
__ TOTAL

HEART
__ Skipped heartbeats
__ Rapid heartbeats
__ Chest pain
__ TOTAL

JOINTS/MUSCLES
__ Pain or aches in joints
__ Arthritis
__ Stiffness, Limited movement
__ Pain, aches in muscles
__ Feeling of weakness or tiredness
__ TOTAL

GRAND TOTAL = ____

LUNGS
__ Chest congestion
__ Asthma, bronchitis
__ Shortness of breath
__ Difficulty breathing
__ TOTAL

MIND
__ Poor memory
__ Confusion
__ Poor concentration
__ Difficulty making decisions
__ Stuttering, stammering
__ Slurred speech
__ Learning disabilities
__ TOTAL

MOUTH/THROAT
__ Chronic coughing
__ Gagging, frequent need to clear throat
__ Sore throat, hoarse
__ Swollen or discolored tongue, gums, or lips
__ Canker sores
__ TOTAL

NOSE
__ Stuffy nose
__ Sinus problems
__ Hay fever
__ Sneezing attacks
__ Excessive mucus
__ TOTAL

SKIN
__ Acne
__ Hives, rashes, dry skin
__ Hair loss
__ Flushing or hot flashes
__ Excessive sweating
__ TOTAL

WEIGHT
__ Binge eating/drinking
__ Craving certain foods
__ Excessive weight
__ Compulsive eating
__ Water retention
__ Underweight
__ TOTAL

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