Symptom Checklist Template

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SYMPTOM LIST
Name: ____________________________________
Date: _____________
Circle any problem, disease or symptom you have now
Underline items that affected you in the past
Skin: eczema
acne
skin rashes
dermatitis
furuncles
fungal infections
warts
psoriasis
Heart and Vascular: fast pulse (over 100 beats/min.)
slow pulse (less than 60 beats/min.)
palpitation
irregular pulse
feeling of pressure in the chest
short of breath
chest pain
dizziness
migraine headache with nausea
cold hands/cold feet
Raynaud’s disease
flushed face
anemia
high blood pressure
cold sweats
red face
feel dizzy or faint when standing up quickly or standing for a long time
Gastrointestinal: constipation
diarrhea
no appetite
stomach pain
indigestion
heartburn
intestinal gas
belching
ulcer
gastritis
lack of stomach acid
hemorrhoids
ileocecal valve spasm
peritonitis
pancreatitis
irritable bowel
polyps
GI tumors
Respiratory: asthma
bronchitis
emphysema
cough
wheeze
pneumonia
lung
abscess
Hormonal Imbalance: low thyroid
overactive thyroid
diabetes
hypoglycemia
blood sugar
Other Hormone Imbalance: ___________________________________________________________
Male: impotence
premature ejaculation
prostate gland problem
vasectomy
infertility
Female: menstrual problems
cramping
heavy/light/irregular periods
PMS
emotional reactions
menopause symptoms
tubal ligation
infertility
low libido
Autoimmune and Inflammatory Conditions: Hashimoto’s disease (thyroid)
rheumatism
systemic lupus
erythematosus
colitis
Crohn’s disease
alopecia (baldness)
allergy
food allergy
atopic dermatitis
neurodermatis
cellulitis
sinus allergy
vulvitis
low immunity

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