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Please read the following symptoms and rate them based on how you have been feeling over the past 30 days.

Fill in the blanks using the appropriate numbers on the key below.

KEY:

0 - No, Never, Almost Never Occurs

1 - Occasionally Occurs, Effect Not Severe

2 - Occasionally Occurs, Effect Severe

3 - Frequently Occurs, Effect Not Severe

4 - Frequently Occurs, Effect Severe

Gastrointestinal

Liver

Skin

Nails

Nose

Eyes

Ears:

Head

Mouth and Throat

Mental/Emotional

Metabolism

Weight

Immune System

Heart/Lungs

Musculoskeletal

Energy Levels

Kidney

OTHER:

Please add the numbers from each section and writhe the total in the space provided under that section X Then add all the totals for each section together and put that total in the space below X

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