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GENERAL :
___ Fatigue, made worse by exertion or stress.
___ Recurrent flu-like illness, sore throat, hoarseness.
___ Shortness of breath with little or no exertion.
___ Tremor or trembling.
___ Severe nasal allergies ( new or worsening of previous allergies.
___ Feeling too cold or feeling too hot.
___ Cold extremities ( hands and feet)
___ Heart palpitations
___ Dryness of eyes and/or mouth.
___ Symptoms worsened by temperature changes.
___ Symptoms worsened by air travel.
___ Symptoms worsened by stress.
PAIN :
___ Headaches
___ Tender points or trigger points.
___ Muscle pain, twitching, spasms and weakness.
___ Paralysis or severe weakness of an arm or leg.
___ Joint pain.
___ TMJ syndrome.
___ Chest pain and/or rib pain (costochondritis)
___Carpal tunnel syndrome.
NEUROLOGICAL :
___ Lightheadedness, feeling "spaced out"
___ Inability to think clearly ( "brain fog" or "fibro fog")
___ Seizure ( fainting) or blackouts.
___ Sensation that you might faint.
___ Vertigo or dizziness.
___ Numbness or tingling sensations, like pins and needles in limbs.
___ Tinnitus ( ringing in one or both ears)
___ Photophobia ( sensitivity to light)
___ Noise intolerance)
EQUILIBRIUM / PERCEPTION :
___Feeling spatially disoriented.
___ Balance difficulty.
___ Clumsy walking or bumping into things.
___ Dropping things frequently.
SLEEP :
___Hypersomnia ( excessive sleeping)
___ Sleep disturbance: unrefreshing or non-restorative sleep ( inability to achieve stage 4 restorative sleep.
___ Difficulty falling asleep.
___ Vivid or disturbing dreams or nightmares.
___ Sleep paralysis related to stage 4 sleep deprivation.
MOOD / EMOTIONS :
___ Depressed mood.
___ Suicidal thoughts or attempts.
___ Feeling worthless.
___ Frequent crying.
___ Feeling help and/or hopeless.
___ Inability to enjoy previously enjoyed activities.
___ Increased or decreased appetite.
___ Anxiety or fear when there is no obvious cause.
___ Panic attacks.
___ Irritability, overreaction.
___ Rage attacks: anger outburst ( may be due to pain)
___ Abrupt, unpredictable mood swings.
___ Phobias (irrational fears)
___ Personality changes.
EYES AND VISION :
___ Eye pain
___ Changes in visual acuity (frequent changes in ability to see well)
___ Blind spots in vision.
SENSITIVITIES :
___ Sensitivity to medications ( unable to tolerate "normal" dosage)
___ Sensitivity to odors ( cleaning products, exhaust fumes, colognes, hair sprays)
___ Sensitivity to foods.
___ Alcohol intolerance.
___ Alteration of taste, smell, and/or hearing.
UROGENITAL :
___Frequent urination.
___ Painful urination or bladder pain (interstitial cystitis)
___ Prostate pain.
___ Impotence.
___ Endometriosis.
___ Worsening of premenstrual syndrome (PMS)
___ Decreased libido ( sex drive)
GASTROINTESTINAL :
___ Irritable Bowl Syndrome.
___ Stomach ache , abdominal cramping.
___ Nausea and /or vomiting.
___ Esophageal reflux (heartburn) and/or GERDS (gastro-esophageal reflux disorder)
___ Frequent diarrhea.
___ Frequent constipation.
___ Bloating, intestinal gas.
___ Decreased and/or increased appetite.
___ Food cravings.
SKIN :
___ Rashes or sores.
___Eczema or psoriasis.

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