Symptom Checklist 

Name

Sex Sex Female Male

Age Age 2-11 12-18 Over 18

Digestive Symptoms? Digestive Symptoms? Reflux Burping Bloating Constipation Poor appetite Stomach Upsets Easily Food Allergies Stomach pains before and after meals

Liver-Gallbladder Symptoms? Liver-Gallbladder Symptoms? Intolerance to fatty foods Light coloured stools Foul smelling stools Less than 1 bowel motion per day Hard stool Sour taste in mouth Bad Breath

Small Intestine Symptoms? Small Intestine Symptoms? Abdominal cramps Indigestion after eating Alternating constipation and diarrhoea Diarrhoea IBS 2-3 Bowel motions per day Dry flaky skin

Large Bowel Symptoms? Large Bowel Symptoms? Recurring infections Bladder and kidney infections Vaginal yeast infection Toe and finger fungus Haemorrhoids Constipation

Large Bowel Symptoms? Large Bowel Symptoms? Recurring infections Bladder and kidney infections Haemorrhoids Constipation Toe and finger fungus

Cardiovascular Symptoms? Cardiovascular Symptoms? High blood pressure Low blood pressure Palpations or racing heart Irregular heart beat Varicose veins Chest pain Poor circulation

Hormonal Symptoms? Hormonal Symptoms? Dizziness when standing Cravings Feel shaky Tired if missed a meal Need coffee to get started Feel tired 1-3 hours after eating Poor memory and concentration Impatient or moody Forgetfulness

Thyroid Symptoms? Thyroid Symptoms? Strong smelling urine Swollen eyes Sensitive to cold Cold hands and feet Chronic Fatigue Depression Low libido Sugar causes irritability Gains weight easily PMS (Premenstrual Syndrome)

Thyroid Symptoms? Thyroid Symptoms? Strong smelling urine Swollen eyes Sensitive to cold Cold hands and feet Chronic Fatigue Depression Sugar causes irritability Gains weight easily

Thyroid Symptoms? Thyroid Symptoms? Strong smelling urine Swollen eyes Sensitive to cold Cold hands and feet Chronic Fatigue Depression Low libido Sugar causes irritability Gains weight easily

Respiratory Symptoms? Respiratory Symptoms? Chest pains Difficulty breathing Coughing up phlegm Runny nose Sore throat Post nasal drip Blocked nose Wheezing Bronchitis Lung infection Cold Flu COVID-19 Sinus Ear infection

Urinary Symptoms? Urinary Symptoms? Bladder infection Kidney infection Burning sensation when urinating Frequent urination

Reproductive Symptoms? Reproductive Symptoms? Regular periods Amenorrhoea (Absence of period) Menorrhagia (Excessive clotting and bleeding) PMS (Premenstrual Syndrome) PME (Premenstrual Exacerbation) PMDD (Premenstrual Dysphoric Disorder) Painful before period Headaches before period Painful during period Headaches during period Bleeding in-between periods Swollen tender breasts Emotionally sensitive before period Cravings carbohydrate foods Cravings salty foods

Reproductive Symptoms? Reproductive Symptoms? Regular periods Amenorrhea (Absence of period) Menorrhagia (Excessive clotting and bleeding) PMS (Premenstrual Syndrome) PME (Premenstrual Exacerbation) PMDD (Premenstrual Dysphoric Disorder) Painful before period Headaches before period Painful during period Headaches during period Bleeding in-between periods Swollen tender breasts Emotionally sensitive before period Cravings carbohydrate foods Cravings salty foods Menopause Genital infections Have an STD Infertility

Reproductive Symptoms? Reproductive Symptoms? Difficulty urinating Dripping after urination Frequent nocturnal urination Burning or pain during urination Have an STD (herpes, etc) Low libido Impotent

Nervous Symptoms? Nervous Symptoms? Nightmares Insomnia Difficulty going to sleep Anxiety Depression Stressed out Restless during sleep Leg cramps Restless legs

Skin Symptoms? Skin Symptoms? Acne Eczema Vitiligo (discolouration on skin) Rashes Skin fungal Psoriasis History of skin cancers Dry skin Sensitive skin

Other symptoms not mentioned above?