Female Intake Questionnaire

General Information

Full Name

Date

Age:

Date of birth

Email *

Address

Street Address

City

State

Country

Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote D"Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea People's Democratic Republic
Republic of Korea
Kuwait
Kyrgyzstan
Land Islands
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States of Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Eswatini
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
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Postal code

Phone

Home
Cell
Work

Genetic Background:

African American

Hispanic

Mediterranean

Asian

Native American

Caucasian

Northern European

Others:

When, where and from whom did you last receive medical or health care?

Emergency Contact:

Relationship

Phone

Home
Cell
Work

How did you hear about our practice?

Clinic website

IFM website

Referral from doctor

Referral from friend/family member

Social media

Other

Current Health Concerns

1. Describe Problem

Severity

Mild

Moderate

Severe

Prior Treatment/Approach

Success

Good

Excellent

Fair

2. Describe Problem

Severity

Mild

Moderate

Severe

Prior Treatment/Approach

Success

Good

Excellent

Fair

3. Describe Problem

Severity

Mild

Moderate

Severe

Prior Treatment/Approach

Success

Good

Excellent

Fair

Allergies

1. Name of Medication/Supplement/Food:

Reaction

2. Name of Medication/Supplement/Food:

Reaction

3. Name of Medication/Supplement/Food:

Reaction

4. Name of Medication/Supplement/Food:

Reaction

5. Name of Medication/Supplement/Food:

Reaction

Lifestyle Review

Sleep

How many hours of sleep do you get each night on average?

Do you have problems falling asleep?

Yes

Do you have problems with insomnia?

Yes

Do you feel rested upon awakening?

Yes

Staying asleep?

Yes

Do you snore?

Yes

Do you use sleeping aids?

Yes

If yes, explain:

Exercise

Current Exercise Program:

Cardio/Aerobic

Type
# of Times Per Week
Time/Duration (Minutes)

Strength/Resistance

Type
# of Times Per Week
Time/Duration (Minutes)

Flexibility/Stretching

Type
# of Times Per Week
Time/Duration (Minutes)

Balance

Type
# of Times Per Week
Time/Duration (Minutes)

Sports/Leisure (e.g., golf)

Type
# of Times Per Week
Time/Duration (Minutes)

Other:

Type
# of Times Per Week
Time/Duration (Minutes)

Do you feel motivated to exercise?

Yes

A little

Are there any problems that limit exercise?

Yes

If yes, explain:

Do you feel unusually fatigued or sore after exercise?

Yes

If yes, explain:

Nutrition

Do you currently follow any of the following special diets or nutritional programs? (Check all that apply)

Vegetarian

Blood Type

Vegan

Low sodium

Allergy

No Dairy

Elimination

No Wheat

Low Fat

Gluten Free

Low Carb

High Protein

Other:

Do you have sensitivities to certain foods?

Yes

If yes, list food and symptoms:

Do you have an aversion to certain foods?

Yes

If yes, explain:

Do you adversely react to: (Check all that apply)

Chocolate

Preservatives

Alcohol

Red wine

Garlic/onion

Cheese

Citrus foods

Food colorings

Artificial sweeteners

Monosodium glutamate (MSG)

Sulfite–containing foods (wine, dried fruit, salad bars)

Other food substances:

Are there any foods that you crave or binge on?

Yes

If yes, what foods?

Do you eat 3 meals a day?

Yes

If no, how many

Does skipping a meal greatly affect you?

Yes

How many meals do you eat out per week?

0-1

1-3

3-5

More than 5 meals per week

Check the factors that apply to your current lifestyle and eating habits:

Fast eater

Eat too much

Late-night eating

Dislike healthy foods

Time constraints

Travel frequently

Eat more than 50% of meals away from home

Healthy foods not readily available

Poor snack choices

Significant other or family members don’t like healthy foods

Significant other or family members have special dietary needs

Love to eat

Eat because I have to

Have negative relationship to food

Struggle with eating issues

Emotional eater (eat when sad, lonely, bored, etc.)

Eat too much under stress

Eat too little under stress

Don’t care to cook

Confused about nutrition advice

Diet

Please record what you eat in a typical day:

Breakfast
Lunch
Dinner
Snacks
Fluids

How many servings do you eat in a typical week of these foods:

Fruits (not juice
Legumes (beans, peas, etc)
Dairy/Alternatives
Cans of soda (regular or diet)
Red meat
Fish
Nuts & Seeds
Fats & Oils
Sweets (candy, cookies, cake, ice cream, etc.)
Vegetables (not including white potatoes)

Do you drink caffeinated beverages?

Yes

If yes, check amounts: Coffee (cups per day)

2-4

More than 4

Tea (cups per day)

2-4

More than 4

Caffeinated sodas—regular or diet (cans per day)

2-4

More than 4

Do you have adverse reactions to caffeine?

Yes

If yes, explain:

When you drink caffeine do you feel:

Irritable or wired

Aches or pains

Smoking

Do you smoke currently?

Yes

Packs per day:

Number of years

What type?

Cigarettes

Smokeless

Pipe

Cigar

E-Cig

Have you attempted to quit?

Yes

If yes, using what methods:

If you smoked previously:

Packs per day:
Number of years

Are you regularly exposed to second-hand smoke?

Yes

Alcohol

How many alcoholic beverages do you drink in a week? (1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits)

1-3

4-6

7-10

More than 10

None

Previous alcohol intake?

Yes

Mild

Moderate

High

None

Have you ever had a problem with alcohol?

Yes

If yes, when?

Explain the problem:

Have you ever thought about getting help to control or stop your drinking?

Yes

Other Substances

Are you currently using any recreational drugs?

Yes

If yes, type:

Have you ever used IV or inhaled recreational drugs?

Yes

Stress

Do you feel you have an excessive amount of stress in your life?

Yes

Do you feel you can easily handle the stress in your life?

Yes

How much stress do each of the following cause on a daily basis (Rate on scale of 1-10, 10 being highest)

Work
Family
Social
Finances
Health
Other

Do you use relaxation techniques?

Yes

If yes, how often?

Which techniques do you use? (Check all that apply)

Meditation

Breathing

Tai Chi

Yoga

Prayer

Other:

Have you ever sought counseling?

Yes

Are you currently in therapy?

Yes

If yes, describe:

Have you ever been abused, a victim of crime, or experienced a significant trauma?

Yes

What are your hobbies or leisure activities?

Relationships:

Marital status:

Single

Married

Divorced

Gay/Lesbian

Long-Term Partner

Widow/er

With whom do you live? (Include children, parents, relatives, friends, pets)

Current occupation:

Previous occupations:

Do you have resources for emotional support?

Yes

(Check all that apply)

Spouse/Partner

Family

Friends

Religious/Spiritual

Pets

Others:

Do you have a religious or spiritual practice?

Yes

If yes, what kind?

How well have things been going for you?

(Enter score on scale of 1-10, with 1 being poorly, 5 being fine, and 10 being very well; choose N/A if not applicable)

How Well Have Things Been Going for You?

Overall
At school
In your job
In your social life
With close friends
With sex
With your attitude
With your boyfriend/girlfriend
With your children
With your parents
With your spouse

History

Patient’s Birth/Childhood History:

You were born:

Term

Premature

Don’t know

Were there any pregnancy or birth complications?

Yes

If yes, explain:

You were:

Breast-fed/How long?
Bottle-fed/Type of formula:
Don’t know

Age of introduction of:

Solid food:
Wheat
Dairy

As a child, were there any foods that were avoided because they gave you symptoms?

Yes

If yes, what foods and what symptoms? (Example: milk—gas and diarrhea)

Did you eat a lot of sugar or candy as a child?

Yes

Dental History:

Check if you have any of the following, and provide number if applicable:

Silver mercury fillings
Caps/Crowns
Problems with chewing
Gold fillings
Tooth pain
Root canals
Bleeding gums
Implants
Implants

Other dental concerns (explain):

Have you had any mercury fillings removed?

Yes

If yes, when:

How many fillings did you have as a kid?

Do you brush regularly?

Yes

Environmental/Detoxification History

Do any of these significantly affect you?

Cigarette smoke

Perfume/colognes

Auto exhaust fumes

In your work or home environment are you regularly exposed to: (Check all that apply)

Mold

Water leaks

Renovations

Chemicals

Electromagnetic radiation

Damp environments

Carpets or rugs

Old paint

Stagnant or stuffy air

Smokers

Pesticides

Herbicides

Harsh chemicals (solvents, glues, gas, acids, etc

Cleaning chemicals

Heavy metals (lead, mercury, etc.)

Paints

Airplane travel

Have you had a significant exposure to any harmful chemicals?

Yes

If yes: Chemical name, length of exposure, date:

Do you have any pets or farm animals?

Yes

If yes, do they live:

Inside

Outside

Both inside and outside

Women’s History

Obstetric History: (Check box and provide number if applicable)

Pregnancies

Vaginal deliveries

Miscarriages

Cesarean

Abortions

Term births

Living children

Premature birth

Birth weight of largest baby

Birth weight of smallest baby

Did you develop any problems in or after pregnancy, for example, toxemia (high blood pressure), diabetes, post-partum depression, issues with breast feeding, etc.?

Yes

If yes, please explain

Menstrual History:

Age at first period

Length of cycle

Date of last menstrual period

Time between cycles

Cramping?

Yes

Pain?

Yes

Have you ever had premenstrual problems (bloating, breast tenderness, irritability, etc.)?

Yes

If yes, please describe:

Do you have other problems with your periods (heavy, irregular, spotting, skipping, etc.)?

Yes

If yes, please describe:

Use of hormonal birth control:

Birth control pills

Patch

Nuva ring

Others:

How Long

Any problems with hormonal birth control?

Yes

If yes, explain

Use of other contraception?

Yes

Choose

Condoms

Diaphragm

IUD

Partner vasectomy

Are you in menopause?

Yes

If yes, age at last period:

Was it surgical menopause?

Yes

If yes, explain surgery:

Do you currently have symptomatic problems with menopause? (Check all that apply)

Hot flashes

Vaginal dryness

Mood swings

Weight gain

Decreased libido

Headaches

Joint pain

Palpitations

Loss of control of urine

Concentration/memory problems

Are you on hormone replacement therapy?

Yes

If yes, for how long and for what reason (hot flashes, osteoporosis prevention, etc.)?

Other Gynecological Symptoms: (Check if applicable)

Endometriosis

Ovarian cysts

Infertility

Fibroids

Vaginal infection

Reproductive cancer

Pelvic inflammatory disease

Sexually transmitted disease (describe):

Gynecological Screening/Procedures: (If applicable, provide date)

Last Pap test:

Result

Normal

Abnormal

Last mammogram

Result

Normal

Abnormal

Last bone density:

Result

High

Low

Within Normal Range

Other tests/procedures (list type and dates):

Family History

Check family members that have/had any of the following

Mother

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Age (if still alive)

Age at death (if deceased)

Father

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Brother

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Sister

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Child

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Family History (continued)

Child #2

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Child #3

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Maternal Grandmother

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Maternal Grandfather

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Family History (continued)

Paternal Grandmother

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Paternal Grandfather

Cancer

Heart disease

Hypertension

Obesity

Diabetes

Stroke

Autoimmune disease

Arthritis

Kidney disease

Thyroid problems

Seizures/epilepsy

Psychiatric disorders

Anxiety

Depression

Asthma

Allergies

Eczema

ADHD

Autism

Irritable Bowel Syndrome

Dementia

Substance abuse

Genetic disorders

Others:

Age (if still alive)

Age at death (if deceased)

Medical History: Illnesses/Conditions

Check YES = a condition you currently have, Check PAST = a condition you’ve had in the past.

Gastrointestinal

Irritable bowel syndrome

Yes

Past

GERD (reflux)

Yes

Past

Crohn’s disease/ulcerative colitis

Yes

Past

Peptic ulcer disease

Yes

Past

Celiac disease

Yes

Past

Gallstones

Yes

Past

Other:

Yes

Past

Respiratory

Bronchitis

Yes

Past

Asthma

Yes

Past

Emphysema

Yes

Past

Pneumonia

Yes

Past

Sleep apnea

Yes

Past

Other:

Yes

Past

Urinary/Genital

Kidney stones

Yes

Past

Gout

Yes

Past

Interstitial cystitis

Yes

Past

Frequent yeast infections

Yes

Past

Frequent urinary tract infections

Yes

Past

Sexual dysfunction

Yes

Past

Sexually transmitted diseases

Yes

Past

Other:

Other

Yes

Past

Endocrine/Metabolic

Diabetes

Yes

Past

Hypothyroidism (low thyroid)

Yes

Past

Hyperthyroidism (overactive thyroid)

Yes

Past

Polycystic ovarian syndrome

Yes

Past

Infertility

Yes

Past

Metabolic syndrome/insulin resistance

Yes

Past

Eating disorder

Yes

Past

Hypoglycemia

Yes

Past

Other:

Yes

Past

Inflammatory/Immune

Rheumatoid arthritis

Yes

Past

Chronic fatigue syndrome

Yes

Past

Food allergies

Yes

Past

Environmental allergies

Yes

Past

Multiple chemical sensitivities

Yes

Past

Autoimmune disease

Yes

Past

Immune deficiency

Yes

Past

Mononucleosis

Yes

Past

Hepatitis

Yes

Past

Other:

Yes

Past

Musculoskeletal

Fibromyalgia

Yes

Past

Osteoarthritis

Yes

Past

Chronic pain

Yes

Past

Other:

Yes

Past

Skin

Eczema

Yes

Past

Psoriasis

Yes

Past

Acne

Yes

Past

Skin cancer

Yes

Past

Other:

Yes

Past

Cardiovascular

Angina

Yes

Past

Heart attack

Yes

Past

Heart failure

Yes

Past

Hypertension (high blood pressure)

Yes

Past

Stroke

Yes

Past

High blood fats (cholesterol, triglycerides)

Yes

Past

Rheumatic fever

Yes

Past

Arrythmia (irregular heart rate)

Yes

Past

Murmur

Yes

Past

Mitral valve prolapse

Mild

Moderate

Severe

Other:

Yes

Past

Neurologic/Emotional

Epilepsy/Seizures

Yes

Past

ADD/ADHD

Yes

Past

Headaches

Yes

Past

Depression

Yes

Past

Anxiety

Yes

Past

Autism

Yes

Past

Multiple sclerosis

Yes

Past

Parkinson’s disease

Yes

Past

Dementia

Yes

Past

Other:

Yes

Past

Cancer

Lung

Yes

Past

Breast

Yes

Past

Colon

Yes

Past

Ovarian

Yes

Past

Skin

Yes

Past

Other:

Yes

Past

Medical History (continued)

Diagnostic Studies

Bone Density

Date
Comments

CT scan

Date
Comments

Colonoscopy

Date
Comments

Cardiac stress test

Date
Comments

EKG

Date
Comments

MRI

Date
Comments

Upper endoscopy

Date
Comments

Upper GI series

Date
Comments

Chest X-ray

Date
Comments

Other X-rays

Date
Comments

Barium enema

Date
Comments

Other:

Input Here
Date
Comments:

Injuries

Broken bone(s)

Date
Comments

Back injury

Date
Comments

Neck injury

Date
Comments

Head injury

Date
Comments

Other:

Input Here
Date
Comments

Surgeries

Appendectomy

Date
Comments

Dental

Date
Comments

Gallbladder

Date
Comments

Hernia

Date
Comments

Hysterectomy

Date
Comments

Tonsillectomy

Date
Comments

Joint Replacement

Date
Comments

Heart surgery

Date
Comments

Other:

Input Here
Date
Comments

Hospitalizations

Input Here
Date
Reasons

Input Here
Date
Reasons

Input Here
Date
Reasons

Input Here
Date
Reasons

Symptom Review

Please check if these symptoms occur presently or have occurred in the last 6 months

General

Cold hands and feet

Mild

Moderate

Severe

Cold intolerance

Mild

Moderate

Severe

Daytime sleepiness

Mild

Moderate

Severe

Difficulty falling asleep

Mild

Moderate

Severe

Early waking

Mild

Moderate

Severe

Fatigue

Mild

Moderate

Severe

Fever

Mild

Moderate

Severe

Flushing

Mild

Moderate

Severe

Heat intolerance

Mild

Moderate

Severe

Night waking

Mild

Moderate

Severe

Nightmares

Mild

Moderate

Severe

Can’t remember dreams

Mild

Moderate

Severe

Low body temperature

Mild

Moderate

Severe

Head, Eyes, and Ears

Conjunctivitis

Mild

Moderate

Severe

Distorted sense of smell

Mild

Moderate

Severe

Distorted taste

Mild

Moderate

Severe

Ear fullness

Mild

Moderate

Severe

Ear ringing/buzzing

Mild

Moderate

Severe

Eye crusting

Mild

Modetrate

Severe

Eye pain

Mild

Moderate

Severe

Eyelid margin redness

Mild

Moderate

Severe

Headache

Mild

Moderate

Severe

Hearing loss

Mild

Moderate

Severe

Hearing problems

Mild

Moderate

Severe

Migraine

Mild

Moderate

Severe

Sensitivity to loud noises

Mild

Moderate

Severe

Vision problems

Mild

Moderate

Severe

Musculoskeletal

Back muscle spasm

Mild

Moderate

Severe

Calf cramps

Mild

Moderate

Severe

Chest tightness

Mild

Moderate

Severe

Foot cramps

Mild

Moderate

Severe

Joint deformity

Mild

Moderate

Severe

Joint redness

Mild

Moderate

Severe

Joint stiffness

Mild

Moderate

Severe

Muscle pain

Mild

Moderate

Severe

Muscle spasms

Milld

Moderate

Severe

Muscle stiffness

Mild

Moderate

Severe

Muscle twitches

Mild

Moderate

Seevere

Around eyes

Mild

Moderate

Severe

Arms or legs

Mild

Moderate

Severe

Muscle weakness

Mild

Moderate

Severe

Neck muscle spasm

Mild

Moderate

Severe

Tendonitis

Mild

Moderate

Severe

Tension headache

Mild

Moderate

Severe

TMJ problems

Mild

Moderate

Severe

Mood/Nerves

Radio 313fct

Option 1

Option 2

Option 3