Patient:_______________________________________Date:_______________________

Symptom Checklist
__Abnormal Tastes __Anxiety __Bladder Infections __Bloating
__Blurring Vision __Brittle Nails __Constipation __Depression
__Diarrhea __Dizziness __Dysuria __Faintness
__Fatigue __Frontal Headaches __Gas __Growing Pains
__Hives __Hunger Tremors __Impaired Concentration __Impaired Memory
__Insomnia __Irritability __Irritated Eyes __Itching
__Leg Cramps __Nasal Congestion __Nervousness __Neurodermatitis
__Numbness __Occiptal Headaches __Pains __Palpitations
__Panic Attack __Pungent Urine __Rashes __Restless Legs
__Ringing Ears __Salt Cravings __Sugar Cravings __Sweating
__Vulvodynia __Weight Changes __Other __Other