Intestinal System Intake Form

Name:
Date:
E-mail:
If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply.
Extreme fatigue
Recurrent vaginal infections
Frequent use of antibiotics
White coated tongue, oral thrush
Crave sugars, bread, alcohol
Headaches
Tonillitis, recurrent strep throat
Itchy, watery or dry eyes
Skin flushes
Chronic indigestion, frequently used antacids
Always cold, especially in extremities
Female: PMS
Pain in pelvic area
Abdominal gas and bloating
Loss of sex drive
Cystitis, repeated bladder infection
Increasing food and chemical sensitivities
Severe reaction to tobacco, perfume, etc.
Female: endometriosis/ovary problems
Chronic diarrhea
Hives, psoriasis, acne, skin rashes
Rectal itching
Abnormal muscle aches from exercise
Excessive wax in ears
Unexpected, unexplained weight gain
Impotence
Canker sores
Athlete's foot, finger/toenail fungus, ringworm
Jock itch
"Brain fog"
Irritability
Memory loss
Mental confusion
Depression or anger for no reason
Anxiety/panic attacks
Inability to concentrate
Phoci/compulsive
Lethargy
Mood swings
Itchy ears, nose or anus
Forgetfulness
Slow reflexes
Gas and bloating
Unclear thinking
Loss of appetite
Yellowish or pale face
Fast heartbeat
Heart pain
Pain in navel
Eating more than normal but still feeling hungry
Blurry or unclear vision
Pain in the back, thighs, shoulders
Numb hands
Drooling while sleeping
Damp lips at night
Grind teeth while asleep
Lethargy; chronic fatigue
Dark circles under eyes
Cancer
Word Verification: