| Group
I Symptoms |
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10 |
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only the boxes on the left
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(DO
NOT manually check any of these boxes) |
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Lack
of Energy |
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Frequent
Illness (more than normal) |
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Body
Odor and/or Bad Breath |
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Difficulty
Digesting Certain Foods |
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Frequent
Consumption of Red Meats |
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Female
Concerns (P.M.S. Menopausal) |
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Use
of Antibiotics Within the Last Three Years |
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Regular
Alcohol Consumption |
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Mood
Swings |
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Food
Allergies |
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Bags
or Dark Circles Under the Eyes |
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Smoking |
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Poor
Concentration or Memory |
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Poor
Resistance to Disease |
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Belching
or Gas After Meals |
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Stressful
Lifestyle |
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Skin/Complexion
Problem's |
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Cravings
for Sweets and Processed Foods |
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| Group
II Symptoms |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Select
only the boxes on the left
|
(DO
NOT manually check any of these boxes) |
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Regular
Consumption of Dairy Products |
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Feelings
of Depression or Uninterest |
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Too
Little Sleep or Restless Sleep |
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Menopausal
Concerns |
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Any
Urinary Concerns |
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Hair
Loss |
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Sore
or Painful Joints |
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Difficulty
Maintaing Ideal Weight |
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Low
Endurance During Activity |
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Poor
Eating Habits |
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Slow
Recovery From Illness |
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Bowel
Activity Less Than Twice Daily |
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Lack
of Appetite |
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Low
Sex Drive |
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Brittle
or Easily Broken Finger Nails |
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Dry,
Damaged, or Dull Hair |
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High-Fat
Diet |
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Feeling
Unsettled, Apprehensive, or Pressured |
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| Group
III Symptoms |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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Select
only the boxes on the left
|
(DO
NOT manually check any of these boxes) |
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Low-Fiber
Diet |
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Asthma,
Hayfever, or Allergies |
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Muscle
Cramps or Spasms |
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Exposure
to Air Pollution (live in the city) |
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Regular
Caffeine Consumption |
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Feeling
Out of Control |
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Food
or CHemical Sensitives |
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Problems
With Yeast or Fungus |
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Weakness
in Joints, Muscles, or Bones |
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Excessive
Worry |
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Easily
Irritated or Angered |
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Too
Little Exercise |
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Excessive
Mucas or Congestion |
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More
Than 10lbs. Overweight |
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Spells
of Rapid or Skipping Heartbeat |
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Blood
Pressure Problems |
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Cold
Hands or Cold Feet |
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Excessive
Thirst |
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| Group
IV Symptoms |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Select
only the boxes on the left
|
(DO
NOT manually check any of these boxes) |
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Eczema,
Psoriasis, or Cracking Skin |
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Swollen
Glands |
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Post
Nasal Drip |
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Frequent
Sinus Problems or Stiffness |
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Feel
Shaky When Hungry |
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Poor
Concentration |
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History
of Stomach Ulcers |
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Diabetic
or High Sugar Consumption |
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Light-Headedness
When Standing Up |
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Colitis,
Diarrhea, or Irratible Bowel |
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