NutriPlex Nutritional Survey
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Please check one or more health problems that apply to you:





The purpose of this Survey is not as a means of diagnosis or treatment but rather to collect information for the purposes of recommending nutritional support.
41 List medications, vitamins and supplements you are taking:
42 What are your greatest health complaints?
AcuTherapy Healing Center
6701 S.W. 72nd Street (Sunset Dr.)
Suite 209
South Miami, FL 33143 

(305) 725-6269

Patricia Kinsley, A.P., Dipl. O.M.
www.AcuTherapyCenter.com

1 Musculoskeletal Injury (injury of back, neck, legs, arms, shoulders, sprains, etc.)
2 Low energy levels (chronic exhaustion, tiredness, no energy)
3 Frequent irritability, mood swings, depression, inability to concentrate or mental exhaustion
4 Skin problems, skin eruptions, skin sores
5 Joint problems, arthritis, aching joints, restriction of joint movement 
6 Tooth and gum problems
7 Respiratory problems
8 Sinus stuffiness or sinus headaches
9 Migraine headaches
10 (Female) PMS, irregular periods, menstrual cramping, menstrual headaches or menopause
11 (Female) current yeast infection:
Are you currently on birth control pills?        
Have you had antibiotics within the last year?
12 Muscle twitching
13 Mouth sores/ulcers, lip sores, fever blisters and/or herpes type sores on mouth/genitalia
14 Leg cramps at night
15 Heart problems: one or more: chest pains, irregular heartbeat, slow or fast pulse
16 Poor circulation in legs or fingers
17 Difficulty with digestion of fatty foods: light colored stools
18 Difficulty with digestion of protein foods: acid stomach, indigestion, heartburn, belching
19 Chest congestion or wheezing or shortness of breath or asthma
20 Seasonal allergies or allergies to animal hair or dust
21 Excessive mental or emotional stress
22 Overall body soreness
23 Itching inside ears
24 Dandruff or flaky scalp
25 Dry eyes
26 Blood sugar problems: either high or low blood sugar, hypoglycemia or diabetes
27 Blackouts or dizziness upon standing
28 Is most of your diet cooked (as opposed to raw)?
29  How frequently do you eat raw green vegetables?
rarely
often
almost every day
30 How frequently do you drink alcohol?
rarely
often 2-3x a week
almost every day
31 Hyperactivity and/or attention deficit (inability to concentrate)
32 High blood pressure
33 High cholesterol
34 Multiple sclerosis
35 Bleeding gums, or gums bleed when brushing teeth
36 Low immune system; frequent colds, flu and sickness
37 Parkinson's Disease or Alzheimers
38 Acne
39 Spider veins, easy or frequent bruising
40 Brittle or soft fingernails