SymptomsEvaluation Please fill in your Symptoms Evaluation Your First Name* Your Last Name* Date of Birth* MM slash DD slash YYYY How to complete this evaluationTake a look at each section and the symptoms listed. If you experience these on a regular basis check the box. As you work through the list you will see that some symptoms are repeated. This is because each section relates to a different area of potential nutritional deficiencies please tick boxes where appropriate. If you're not sure, leave the box blank. Only check the box if you experience the symptoms regularly . Once you have ticked the relevant symptoms, we will total score for each nutrient and talk through the results with you on our next meeting. Ready? Good, let’s get started!Section 1 Mouth ulcers or cold sores Reduced night vision Acne, rashes, or skin infections Frequent collects or infections Dry, flaky skin or itching skin Dandruff or dry scalp Thrush or cystitis Athlete’s foot Diarrhoea or mushy, watery stools Section 2 Back pains Tooth decay Hair loss Muscle twitching or spasms Joint pain or stiffness Weak bones Arthritis or osteoporosis Section 3 Exhaustion after light exercise Easy bruising Slow wound-healing Varicose veins Poor skin elasticity Loss of muscle tone Lack of sex drive Infertility Section 4 Frequent colds Lack of energy Bleeding or tender gums Easy bruising Nosebleeds Slow wound-healing Red pimples on skin Obesity Section 5 Tender muscles Eye pains Irritability Poor concentration Numb, prickly or tingling legs Poor memory Stomach pains Constipation Tingling hands Rapid heartbeat Section 6 Sensitivity to bright lights Sore tongue Eye cataracts Dull or oily hair Eczema or dermatitis Split nails Cracked lips Bloodshot, burning or gritty eyes Section 7 Lack of energy Diarrhoea Insomnia Headaches or migraines Poor memory Anxiety or tension Depression Irritability Obesity Section 8 Muscle tremors, cramps or spasms Lethargy Poor concentration Burning feet or tender heels Nausea or vomiting Lack of energy Exhaustion after light exercise Anxiety or tension Teeth-grinding Section 9 Water retention Infrequent dream recall Tingling hands Depression Nervousness Irritability or bad temper Muscle tremors, cramps or spasms Lack of energy Obesity Section 10 Poor hair condition Eczema or dermatitis Mouth over-sensitive to heat or cold Irritability Anxiety or tension Lack of energy Constipation Tender or sore muscles Pale skin Section 11 Eczema Cracked lips Prematurely greying hair Anxiety or tension Poor memory Lack of energy Depression Poor appetite Stomach pains Migraines Section 12 Dermatitis or dry skin Poor hair condition Prematurely greying hair Tender or sore muscles Poor appetite or nausea Section 13 Bowel inflammation Easy bruising Slow wound-healing Anaemia Bleeding of the gums or nose Heavy menstrual bleeding in women Section 14 Dry skin or eczema Dry hair or dandruff Excessive thirst or sweating PMS or breast pain Water retention Frequent infections Poor memory or learning difficulties High blood pressure or high blood lipids Inflammatory problems, e.g. joint inflammation Section 15 Muscle cramps, tremors or spasms Insomnia or nervousness High blood pressure Tooth decay Joint pain, joint inflammation or arthritis Section 16 Musical cramps, tremors or spasms Muscles weakness Insomnia, nervousness or hyperactivity High blood pressure Irregular or rapid heartbeat Constipation Fits or convulsions Breast tenderness or water retention Depression or confusion Section 17 Pale skin Hair loss Brittle Sore tongue Fatigue, lethargy or weakness Loss of appetite or nausea Heavy periods or blood loss Low immunity Anaemia Section 18 White marks on more than two fingernails Frequent infections Stretch marks Acne or greasy skin Desensitised to pungent smells Intense food cravings Need for extreme sweetness, saltiness or spiciness bland foods are unappetising Obesity Section 19 Joint pains Sore knees Muscles twitches or ticks Dizziness or poor sense of balance Fits, convulsions, or epilepsy history Section 20 Frequent infections High blood pressure Signs of premature ageing Eye cataracts Family history of cancer Section 21 Excessive or cold sweats Cold hands Need for frequent meals Frequent carbohydrate cravings Dizziness or irritability after 6 hrs without food Need for excessive sleep Lethargy during the day Section 22 Muscle cramps or weakness Irritability, confusion or mental tiredness Vomiting or nausea Swollen abdomen or diarrhoea Low blood pressure Cellulite Your results will be discussed during your next client meeting. Having finished this evaluation, you may have concerns about your health and the symptoms you have checked. Do talk to your Medical Doctor or General Practitioner as soon as possible and follow their advice. Next, click the submit button below to complete and send your Symptom Evaluation
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