Place an X in the box that most
appropriately describes any symptoms
you have
suffered over the past 3 months -
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0 |
1 |
2 |
3 |
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1 |
Does your hair tend to fall out or break easily
?
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2 |
Have you been on a strict
weight loss diet in the last 2 years ? |
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3 |
Is your vision at dusk or
at night time poorer now than before ? |
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4 |
Is the skin on the back of
your arms rough, thickened or scaly ? |
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5 |
Do you suffer from
flatulence ? |
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6 |
Do you suffer from
abdominal bloating, especially after eating ? |
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7 |
Do you have bad breath or
a bad taste in the mouth especially on wakening ? |
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8 |
Do you suffer from
frequent coughs or colds ? |
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9 |
Do you have chronic or
recurrent sinus congestion or catarrh ? |
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10 |
Do you get sore red gums
or gums that bleed easily on brushing your teeth? |
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11 |
Do you find that you
bruise easily ? |
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12 |
Do you suffer from
excessive dental plaque and/or caries ? |
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13 |
Do you get muscle
tenderness or weakness in your legs ? |
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14 |
Do you get a burning
feeling in your tongue or lips ? |
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15 |
Do you get palpitations
racing heartbeat or irregular heartbeat ? |
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16 |
Do you get numbness or
tingling sensations in your hands or feet ? |
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17 |
Is your tongue sensitive
to hot drinks or sore ? |
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18 |
Do you get cracks or
soreness
in the corner of your mouth ? |
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19 |
Do you get soreness
burning or gritty feelings in your eyes ? |
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20 |
Are you sensitive to
bright lights ? |
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21 |
Do you have a tendency to
dandruff or excessively oily skin ? |
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22 |
Do you get a reddish
coloration around your nose and ears ? |
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23 |
Do you drink more than 2
glasses of alcohol per day average ? |
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24 |
Do you have a tendency
towards eczema or other skin rashes ? |
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25 |
Do you get dizzy or
light-headed on standing up ? |
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26 |
When on your feet for a
long time do your feet swell or your shoes feel tight
? |
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27 |
Do you get cold fingers or
toes especially at night ? |
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28 |
Do your finger joints or
toes feel stiff or sore on awakening ? |
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29 |
Do you find you seldom
dream or only dream infrequently ? |
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30 |
Do you find that you do
not remember your dreams ? |
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31 |
Do you crave sweet or
sugary foods? |
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32 |
Do you eat white bread and
pasta, sugar or white rice on most days? |
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33 |
Do you sunburn easily
? |
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34 |
Do you react to Monosodium
Glutamate –(e.g. react to Chinese food)? |
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35 |
Do you tend to become
easily excited or irritated ? |
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