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Are you wearing...

Heel lifts

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Has anyone in your family had:

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Thyroid Disease?

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Arthritis?

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Are you frequently ill?

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Are you having:

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At night?

Loss of appetite

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Lyme Disease

Nose and Throat

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Sinus trouble

Hay fever

Allergies

Nasal polyps

Hoarseness or change in voice

Significant alteration in taste or smell

Thyroid disease

Chest

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Asthma or wheezing

Frequent cough

Shortness of breath at rest

Shortness of breath with exertion

Shortness of breath at night

Frequent cough

Coughed up blood

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Heart problems

High blood pressure

Elevated cholesterol

Chest pain or discomfort

Leg or ankle swelling

Thumping, racing or skipping of the heart

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Trouble swallowing

Nausea or vomiting

Ulcer

Heartburn

Abdominal pain

Gallbladder disease

Colon polyps

Genitourinary

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Frequent urination

History of bladder or kidney infection

Sometimes lose control of your bladder

Burning pain

Blood in urine

Trouble starting or stopping urine flow

Bones and Joints

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Joint pain or stiffness

Osteoporosis

Muscle weakness

Muscle cramps with walking

Red/swollen

Gout

Muscle cramps at night

Muscle tenderness

Osteopenia

Neurological

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Frequent or severe headaches

Fainting or loss of consciousness

Seizure or convulsion

Bothered by a spinning sensation or vertigo

Balance problem

Numbness

Lightheadedness

Difficulty walking

Tingling or weakness in your arms

Tingling or weakness in your legs

Changes in bowel/bladder

Loss of control

Lyme Symptoms

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Fever

Chills

Sweats

Muscle Aches

Fatigue

Depression

Nausea

Joint Pain

Rash

Facial Drooping

Brain Fog

If by physician referral, please provide their information below:

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