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“All we need to make us happy is something to be enthusiastic about”
~Albert Einstein (1879-1955)
 
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Symptoms
Headaches   Anxiety     Thinning Skin
  Sleep Problems   Panic     Reduced Libido
  Fatigue/Tiredness   Depression     Osteoporosis
  Sinuses/Allergies   Lethargy     Weight Gain
  Moodiness   Poor Memory     Weight Loss
  Irratability   Poor Concentration     No Appetite
  Tension in Neck   Hot Flashes     Extra Appetite
  Digestive Problems   Night Sweats     Heart Disease
                   

Do you have any symptoms not listed above? Describe.

 
Which of the above symptoms bothers you the most?
   

How long has this been going on?

   
If you could change one thing about your health, what would it be?
   
Would you like to get rid of the problem?
   
If the answer is yes, please select from the following choices:
  I would like to come to your office
  I would like you to call me
  I would like to sign up for today's special offer!
     

 

 
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