AllergiesAsthmaBack/neck painCold hands/feetConstipationDiarrhoeaDizzinessFaintingFatigue/lethargyFrequent urinationHeadachesIndigestion/refluxJoint painMood swingsSciaticaSkin problemsSwollen/painful glandsOther

Absent mensesHot flushesPainful mensesPMS

AlcoholismArthritisAsthma/respiratory problemsBlood disordersCancerCardiovascular disease/symptomsDiabetesEpilepsyHayfever/sinusHepatitis/liver problemsHIV/AIDSHormonal problemsInflammatory bowel disease (IBD)Kidney/bladder problemsMental disordersRoot canal therapySkin disordersStomach ulcersThyroid diseaseOther

YesNo

12345678910

12345678910