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Health: Click to check as many that apply to you now:

Head (HE)

Itchy Scalp      Hair Falling Out     Dandruff

Head Throat Other 
Zits, Rosacea, Herpes / cold sores,

CV - Cardio Vascular
Cold Hands / Feet     High Blood Pressure     
Low Blood Pressure
Total High      HDL Low      LDL High
GI - Gastro Intestinal
Upper Gas / Burping      Heartburn / Stomach Acid  
Acid Reflux      Ulcers      No Appetite
craving food (Please list) 

EE - Ears / Eyes
Itchy Ears     Tinnitis, ringing in the ears     Loss of hearing
Itchy Eyes      Watery Eyes      Conjuctivitis     Red eyeS

NT - Nose / Throat

Runny Nose      Snore      Sneeze Often     
Sore Throat Often

Stiff Neck      Weight Gain      Weight loss    
Thyroid Hypo / Hyper      Stiff Neck

El - Elimination

Gas      Constipation      Polyps      Hemorrhoids

RT - Respiratory / Breathing
Wheeze      Pneumonia      Asthma   
Bronchitis      Breathing Medication(s)
Cough      Allergies from Air      Allergies from Food
MS - Muscle / Skeletal
Joint pain.       Osteoarthritis      Arthritis     Osteoporosis
C2-C7: Cervical ( Neck ) Spine Problems     
T1-T12: Thoracic Spine Problems
L1-L5: Low Back 
S1-S4: Tail Bone
Buldged Disc
Herniated Disc
Desiccated Disc
Spine Pain

SL - Sleep
Sleep problem.  
feel tired often,

Medication Name (s): Dose amount not needed

Supplements: Herbs, Vitamins, Minerals and other

Main Health Concern(s), Things that bother me the most...

Surgeries: Year/Type

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