Essential Nutrient Symptoms Checklist
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- Catherine Aileen Nichols
- 6 years ago
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1 Nutrient s Checklist s can be caused by deficiencies or excesses, associated with them, or part of what causes them. There is often a combination of these factors present. Keep in mind that the presence of the symptom may be indicative of the presence of imbalance, but the causes and associations can be complex. Using this checklist helps to narrow down the possibilities that these deficiencies or excesses may be present and is a tool to help your doctor with clinical diagnosis. (see Note 1 at end of list for examples) Rate Your s from (severity/frequency) Vitamins See Note 4 Abdominal: low pain, cramps, stomach pain, heartburn Absorbing new information difficulties Alcohol consumption: Exaggerated symptoms or hangover, intolerance Allergies: increased, excess mucous Allergies: food Alzheimer's symptoms* Anemia Anger/Apathy/Hostility/Rage: increased/quick to anger Anxiety, panic attacks Appetite loss Asthma Attention: less, poor, short Attention Deficit Disorder (ADD)* Attention Deficit Hyperactivity Disorder (ADHD)* Autism* Back Pain (unexplained) Balance off, "tippy" feeling Bladder dysfunction/irritable Bladder Bladder Infections Bleeding: Excessive or wide-spread Blood Clots (Excessive) Blood in Urine, dark urine Body Odor (unusual) Bone Pain Bones fragile, fracture easily Bowel function change: diarrhea, constipation Brain Fog Breast milk production (unexplained) Breast pain (unexplained) Breathing difficulty: "air hunger", chronic cough, asthma (unexplained) Bruising easily Burning/stabbing sensations Cardiac Impairment Celiac disease* Charley Horses Chest wall pain Chills (unexplained) Chronic fatigue syndrome* Circulation, reduced, poor Cognitive problems Colitis (Inflammation of large intestine/colon) Page 1 of 5 Copyright LivingLyme.com
2 Nutrient s Checklist Rate Your s from (severity/frequency) Vitamins See Note 4 Coma Concentrating/thinking difficulties Confusion Congestion: head, sinuses Constitutional s (affecting the whole body) Convulsions Coordination difficulties, lack of Cravings: Sugar, alcohol Cravings: Fatty foods Crohn's disease symptoms* Diabetes, blood sugar disruption (low or high) Dementia symptoms* Dental: tooth decay, peridontal disease Dental Pain: teeth, jaw joint, face muscles Depression/Despair Disorientation, getting lost, going to wrong places Dizziness, lightheaded, spinning, vertigo x Dreams: Vivid or violent Dry cough Dry throat Ears: buzzing, ringing, ear pain, decreased hearing, sound sensitivity Emotions: over-emotional reactions, hypersensitive, cry easily Encephalitis (inflammation of the brain) Encephalopathy (brain dysfunction) Epilepsy Eyes: blindness, loss of vision Eyes: Conjunctivitis Eyes: doubled/blurred vision Eyes: dryness Eyes: increased floaters Eyes: light sensitivity, photophobia Eyes: night blindness Eyes: Retinitis (swelling of Retina) Eyes: swelling/inflammation Facial paralysis (Bell's palsy) Fatigue, tiredness, poor stamina Feet: shooting, burning pains, sore soles (especially in the morning) Fevers (unexplained) Fevers: High (unexplained) Flu-like symptoms (early symptoms) Flushing (unexplained) Forgetfulness Fibromyalgia symptoms* Gastrointestinal Disorders/ Gastritis Genital discharge (abnormal) Growth: abnormal, depressed Page 2 of 5 Copyright LivingLyme.com
3 Nutrient s Checklist Rate Your s from (severity/frequency) Vitamins See Note 4 Hair loss (unexplained), dry, brittle hair Headaches Heart: Angina (chest pain caused by reduced blood flow to heart. Pain often spreads to shoulder, arms, and neck.) Heart: Arrhythmia (beats too fast or slow) Heart: Block on EKG Heart: Endocarditis (inflammation of lining of heart) Heart: Murmur Heart: Palpitations, skips Heart: Mitral Valve Prolapse Hemolysis (rupture or destruction of red blood cells) Hives Hormonal Imbalance Hot Flashes Hypertension (High blood pressure) Hypotension (Low blood pressure) Hypoglycemia Hyperthyroidism Hypothyroidism Immune dysfunction, weakened immune system Infections (frequent, recurrent): Sinus, Ear, Vaginal, Bladder, etc Infertility Insomnia Interstitial Cystitis* Irritability Irritable Bowel Syndrome, Inflammatory Bowel Disease* Itching: Genitals, Anal Itching: Skin Jaundice Joints: pain, stiffness, swelling (fingers, toes, ankles, wrists, knees, elbows, hips, shoulders, back, neck) Kidneys: dysfunction, stones Leaky Gut Syndrome* Leukopenia (Low White Blood Cell count) Liver: Elevated Enzymes Lou Gehrig's disease symptoms (ALS)* Low body temperature Low White Blood Cell count Lupus symptoms* Lycopenia (skin discoloration) Lymph Nodes/Glands: swollen, pain (persistent) Malaise Meningitis (inflammation of the protective membrane around the brain) Menstrual irregularity (unexplained) Migraines Mood swings Page 3 of 5 Copyright LivingLyme.com
4 Nutrient s Checklist Rate Your s from (severity/frequency) Vitamins See Note 4 Mouth: bad breath, burning tongue, canker sores, mouth blisters, bleeding teeth or gums, pain in teeth Mouth: metallic taste Mouth: black lines or spots on gums Multiple Sclerosis symptoms (MS) (including white matter lesions in head)* Multi-tasking difficulties Muscle weakness (obvious, unusual) Muscle pain, cramps, Myalgia Nail fungus, discoloration; dry, brittle nails Name blocking/difficulty finding words Nausea, vomiting, queasy Neck: stiffness, pain, creaks and cracks Need to sit or lay down (intense, unavoidable) Nervous System: damage, dysfunction Night sweats Numbness Organs: damage, inflammation, failure (liver, kidney, heart, etc.) Osteoporosis* Pain during intercourse Paralysis Parkinson's disease symptoms* Pelvic pain Pneumonia Problem solving difficulties Psychiatric: hallucinations, delusions, paranoia, bipolar, suicidal thoughts, obsessive-compulsive, personality changes Rash: Erythema Migrans (bulls-eye) Rash: Papular or angiomatous (Red line resembling stretch marks) Rash: Maculopapular (flat red area with small bumps) Rash: Petechial (small flat red or purple dots) Rash: Diaper, small itchy red bumps Rash: unspecified Reading difficulty Restless (or Jerky) leg syndrome Rheumatoid Arthritis (and other forms of arthritis)* x Rib soreness Rickets Seizures Sensitivity to heat or cold Sensitivity to light Sensitivity to sound Sensitivity to smells (chemical sensitivity) Sexual dysfunction/loss of libido Shooting pains Shortness of breath, shallow breathing Page 4 of 5 Copyright LivingLyme.com
5 Nutrient s Checklist Rate Your s from (severity/frequency) Vitamins See Note 4 Short-term memory loss Skin: Acne Skin: Athlete's foot Skin: hypersensitivity Skin: flaking, chapped, dry, Eczema, Psoriasis, Dermatitis Sleep Disturbance: too much, too little, fractionated Sore throat Speech difficulty: errors, wrong words, misspeaking Stiffness of joints or back Sweats, sweating (unusual) s flare every 4-6 weeks, come and go, change Testicular Pain Thirst/dehydration (excessive) Tibia pain (severe) Tingling, electrifying feeling. Thrombocytopenia (abnormally low amount of platelets) Thrush (white film in mouth) Thyroid dysfunction Tinnitus (ringing in the ears) Told repeatedly by doctors "It is all in your head" Tongue: Sore Tremors Twitching of face or muscles Ulcers: genital Ulcers: oral, skin Vaginal yeast infection (Candidiasis) Vaginitis Vocal Paralysis Weakness Weight loss or gain (unexplained) Writing difficulty Note 1: An example of this is Hormonal Imbalances can be caused by deficiencies or excesses in vitamins, minerals, amino acids, and/or fatty acids. An excess or deficiency in one can create excess or deficiencies in the others. All aspects of nutrition interrelate and have equal importance in our vital functions. Note 2: You do not have to have all of the symptoms listed to have a particular deficiency or excess. It is always possible to have various underlying conditions present at the same time. This is why it is crucial to work closely with your doctor for diagnosis and treatment. Self-diagnosis and treatment without the oversight of a licensed physician can be dangerous. *Note 3: These are some of the most commonly misdiagnosed diseases on the symptoms list. There are over 350 diseases and syndromes that have common symptoms with Lyme disease and its co-infections. This does not mean that these diseases are or are not present, it just notes that symptoms of these diseases can be seen with other underlying conditions. Note 4: Endocrine or Hormone imbalances vary between men and women, and depending on which part of the endocrine system is imbalanced. Amino Acid and Fatty Acid imbalances can also vary from person to person and can affect the Endocrine system. s shown for these items are generalized and can be interrelated. If you suspect any of these may be an issue, please see your physician for further testing. Page 5 of 5 Copyright LivingLyme.com
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
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Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
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Northern Monmouth County Medical Associates
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Patient History Form
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Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
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J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
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WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Nicole Schertell, ND, CCT Johanna Mauss, ND
Nicole Schertell, ND, CCT Johanna Mauss, ND 603-610-8882 Patient Name: DOB: Section A Do you remember being bitten by a tick? Yes No. If yes, when? Do you remember having the "bulls eye" rash? Yes No Do