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Name:
E-Mail:
Street Address:
City: State: Zip Code:
Phone Number (just numbers):
Age:
Birthdate (mm/dd/year):
Height: Weight:
General Fibromyalgia Symptoms
Fatigue? Yes     No
Length of Time:
Headache? Yes     No
Recurrent Sore Throats? Yes     No
Nausea? Yes     No
Vomitting? Yes     No
Diarrhea? Yes     No
Tender Points/Trigger Points? Yes     No
Tender Lymph Nodes? Yes     No
Muslce Aches, Migratory? Yes     No
Joint Aches, Migratory? Yes     No
Low Grade Fever? Yes     No
Night Sweats? Yes     No
Chills? Yes     No
Loss of Appetitie? Yes     No
Poor Memory? Yes     No
Difficulty Concentrating? Yes     No
Insomnia Or Other Sleep Disturbances? Yes     No
Depression? Yes     No
Irritability? Yes     No
Medical History
Have You Had Any Surgery? Yes     No
If yes, what surgery and when?:
Do You Have Hypertension? Yes     No
Do You Have A Rapid Heartbeat? Yes     No
Do You Have Hypertension? Yes     No
Do You Take Blood Thinners or Aspirin? Yes     No
Do You Have An Ulcer? Yes     No
Have You Had Cancer? Yes     No
If yes, what type and when:
Do You Take Any Supplements? Yes     No
If yes, please list them:
Have You Had Any X-Rays Done? Yes     No
Do You Have Any Other Significant Medical Issues? Yes     No
If yes, please list them:
Symptoms - Please Select "Yes" For Any You Experience
--- MUSCULOSKELETAL --
Arthritis-Degenerative Or Rheumatoid Yes     No
Muscle Or Bone Pain Yes     No
"Growing Pains" Yes     No
Fibromyalgia Yes     No
Migratory Tendonitis Yes     No
Stiffness Or Limitation Of Movement Yes     No
Extreme Muscle Fatigue Yes     No
--- EARS, NOSE & THROAT --
Sinus "Trouble" Yes     No
Thick Post-Nasal Drip Yes     No
Sinus or Nasal Polyps Yes     No
Chronic Stuffy Nose Yes     No
Fluid In Ears Yes     No
Dizziness Yes     No
Meniere's Disease Yes     No
Frequently Clears Throat Yes     No
Frequent Sore Throats Yes     No
Canker Sores In Mouth Yes     No
Bad Breath Yes     No
Metallic Taste In Mouth Yes     No
Intermittent Hoarseness Yes     No
--CARDIOVASCULAR--
Rapid or Irregular Heartbeat Yes     No
Prolapsed Mitral Valve Syndrome In Healthy People Yes     No
Edema Of Extremities Yes     No
High Blood Pressure, Especially In The Young Yes     No
--NEUROLOGIC--
Depression Yes     No
Fatigue Yes     No
Migraines Yes     No
Headaches - Tension, Cluster, Or Sinus Yes     No
Anxiety Or Iritability Yes     No
Quick Temper Or Impatience Yes     No
Short Attention Span Yes     No
Mental Confusion- Inability To Focus Yes     No
ADD Or ADHD Yes     No
Poor Short- Term Memory Yes     No
Behavior Problems Yes     No
--DERMATOLOGIC--
Eczema Yes     No
Rash or Hives Yes     No
Dry, Itchy Skin Yes     No
Acne, Teenage And Adult Yes     No
Acne Rosacea Yes     No
--ENDOCRINE--
Hypoglycemia Yes     No
Hyperglycemia/Diabetes Yes     No
Low Thyroid Yes     No
Weight Gain (No Diet Works) Yes     No
--CHEST--
Asthma Yes     No
Chronic Bronchitis Yes     No
Chronic Cough Yes     No
Tightness In Chest Yes     No
--GENITOURINARY--
Frequent Urination/Interstitial Cystitis Yes     No
Vaginal Itching Or Discharge Yes     No
Chronic Yeast Infections Yes     No
PMS - Fluid Retention, Irritability, Or Severe Cramps Yes     No
--GASTROINTESTINAL--
Heartburn Yes     No
Frequent Gas or Belching Yes     No
Bloating Yes     No
Diarrhea Yes     No
Constipation Yes     No
Vomiting Yes     No
Irritable Bowel Syndrome (IBS) Yes     No
Colitis Yes     No
Ulcerative Colitis Yes     No
Crohn's Disease Yes     No
Reflux Esophagitis Yes     No
Do You Eat Any Of The Following More Than 3 Times Per Week?
Milk Yes     No
Corn Yes     No
Soy Yes     No
Eggs Yes     No
Wheat Yes     No
Tomato Yes     No
Chocolate Yes     No
Brewer's Yeast (Found In Beer And Wine) Yes     No
Baker's Yeast (In Bread) Yes     No
Baked Sweets (Cookies, Donuts, Cakes, Sweet Breads) Yes     No
Speciality Diet, ie. Vegan, Macrobiotic Yes     No
Use This Box For Any Additonal Comments: