Rate each of the following symptoms based upon your health profile for the past 30 days. Print it out and return it to us.
POINT SCALE
0= never or almost never have the symptom
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
DIGESTIVE
___ Nausea or vomiting
___ Diarrhea
___ Constipation
___ Bloated feeling
___ Belching, passing gas
___ Heartburn
___ TOTAL
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
LUNGS
___ Chest congestion
___ Asthma, bronchitis
___ Shortness of breath
___ Difficulty breathing
___ TOTAL
MIND
___ Poor memory
___ Confusion
___ Poor concentration
___ Poor coordination
___ 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, 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
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
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
______GRAND TOTAL
I was really impressed with the advanced equipment and techniques
"In April of 2008 I was struck by another car while driving and felt my neck snap and muscles in my upper body pull and tear. When I woke up the next day I had a migraine and was so stiff I could not walk. Dr. Iris saw me immediately and began working on me. I was really impressed with the advanced equipment and techniques she uses on accident victims. She eliminated my headache in the first visit and got me walking without pain quickly. I would never see or recommend another chiropractor as long as Dr. Iris is still practicing. She is such a wonderful person and talented professional."