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FirstLine Therapy® Health Profile

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FULL NAME EMAIL DATE

Rate each of the following symptoms based upon your typical health profile for the past 30 days
Use this Point Scale to complete form below.	0	Never or almost never have the symptom				3	Frequently have it, effect is *not severe*
	1	Occasionally have it, effect is not severe				4	Frequently have it, effect *is severe*
	2	Ocasionally have it, effect is severe


HEAD Headaches Faintness Dizziness Insomnia Total MOUTH / THROAT Chronic coughing Gagging, frequent need to clear throat Sore throat, hoarseness, loss of voice Swollen or discolored tongue, gums or lips Canker sores TOTAL HEART Irregular or skipped heartbeat Rapid or pounding heartbeat Chest pain TOTAL WEIGHT Binge eating/drinking Craving certain foods Excessive weight Compulsive eating Water retention Underweight TOTAL MIND Poor memory Confusion, poor comprehension Poor concentration Poor physical coordination Difficulty in making decisions Stuttering or stammering Slurred speech Learning disabilities TOTAL		EYES Watery or itchy eyes Swollen, reddened or sticky eyelids Bags or dark circles under eyes Blurred or tunnel vision (don't include near/far sightedness) Total NOSE Stuffy nose Sinus problems Hay fever Sneezing attacks Excessive mucus formation TOTAL LUNGS Chest congestion Asthma, bronchitis Shortness of breath Difficulty breathing TOTAL JOINTS / MUSCLE Pain or aches in joints Arthritis Stiffness or limitation of movement Pain or aches in muscles Feeling of weakness or tiredness TOTAL EMOTIONS Mood swings Anxiety, fear, nervousness Anger, irritability, aggressiveness Depression TOTAL		EARS Itchy ears Earaches, ear infections Drainage from ear Ringing in ears, hearing loss Total SKIN Acne Hives, rashes, dry skin Hair loss Flushing, hot flashes Excessive sweating TOTAL DIGESTIVE TRACT Nausea, vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain TOTAL ENERGY / ACTIVITY Fatigue, sluggishness Apathy, lethargy Hyperactivity Restlessness TOTAL OTHER Frequent illness Frequent or urgent urination Genital itch or discharge TOTAL
GRAND TOTAL


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