Fevers 

□ 

Vertigo 

□ 

Sweats (especially night sweats) 

□ 

Tremors 

□ 

Chills 

□ 

Static Shocks 

□ 

Flushing 

□ 

Confusion 

□ 

Temperature Regulation/Dysregulation Issues 

□ 

Difficulty Focusing 

□ 

Rash 

□ 

Forgetfulness 

□ 

Fatigue, tiredness, poor stamina 

□ 

Poor short term memory 

□ 

Weakness 

□ 

Disorientation, getting lost 

□ 

Unexplained hair loss 

□ 

Difficulty with speech 

□ 

Swollen glands 

□ 

Word-finding problems 

□ 

Sore throat 

□ 

Reversing numbers or letters 

□ 

Testicular pain 

□ 

Difficulty writing 

□ 

Pelvic pain 

□ 

Decreased retention of new knowledge 

□ 

Unexplained menstrual irregularity 

□ 

Mood swings 

□ 

Breast pain 

□ 

Depression/ anxiety 

□ 

Unusual/Unexplained Pain 

□ 

Disturbed sleep 

□ 

Bladder irritability/ dysfunction 

□ 

Increased Urinary frequency 

□ 

Sexual dysfunction/ Loss of libido 

□ 

Abdominal pain 

□ 

Appetite Swings 

□ 

Excessive Thirst 

□ 

Metallic Taste 

□ 

Nausea 

□ 

Constipation 

□ 

Diarrhea 

□ 

Chest pain 

□ 

Rib soreness 

□ 

Shortness of breath 

□ 

Cough 

□ 

Heart palpitations, pulse skips 

□ 

Morning Stiffness 

□ 

Neck stiffness 

□ 

Neck cracks 

□ 

Neck pain 

□ 

Joint stiffness 

□ 

Back pain/Stiffness 

□ 

Joint swelling 

□ 

Joint pain 

□ 

Muscle pain 

□ 

Muscle cramps 

□ 

Twitching of muscles 

□ 

Headache 

□ 

Ice Pick Pain 

□ 

Numbness/ Tingling 

□ 

Skin Sensitivity 

□ 

Facial paralysis 

□ 

Sinus Pain/Pressure 

□ 

Blurry vision 

□ 

Floaters 

□ 

Light sensitivity 

□ 

Tearing 

□ 

Red Eyes 

□ 

Ear buzzing/ ringing 

□ 

Ear pain 

□ 

Sound sensitivity 

□ 

Poor balance 

□ 

Lightheadedness, wooziness 

​

Bone Pain

□ 

Other: ________________________