Name *

First Name

Last Name

Chronic fatigue for no apparent reason

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Swollen or achy joints

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Increased appetite, hungry after meals

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Eat out at restaurants

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Nervous or irritable

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Restless sleep/teeth grinding during sleep

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Night sweats

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Blurry, unclear vision

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Fevers of unknown origin

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Frequent colds, flu, sore throats

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Constipation

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Diarrhea alternating with constipation

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Thinning or loss of hair

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Elevated A.M. cortisol (on saliva tests)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Irritable bowel

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Rectal or anal itching

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Bloating or gas

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Abdominal or liver pain/cramps

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Mucus in nose that is moist or encrusted

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Dark circles under eyes

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Bowel urgency

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Skin problems, rashes, hives, itchy skin

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Vertical wrinkles around mouth

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Kiss pets, allow pets to lick your face

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Go barefoot outside the home

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Travel in Third World countries

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Eat lightly cooked pork/salmon products

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Eat sushi, sashimi

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Swim in creeks, rivers, lakes

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

History of parasitic infection

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Loose stools or diarrhea

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Pale, anemic, or yellowish skin

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Foul-smelling stools

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Low-back or kidney pain

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Indigestion, malabsorption

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree