*Note: The form must be completed in one go. If you exit the form without completion, your answers will be lost and you'll have to start again. Please allow around 15 minutes to complete.

First Name *

Last Name *

Phone *

Email *

Height (cm) *

Weight (kg) *

Have you been diagnosed with, experienced, or undergone any of the following:

Anemia

Anorexia

Anxiety

Depression

Chronic Fatigue

Diabetes Type 1

Diabetes Type 2

Endometriosis

Gallbladder Removal

Graves Disease (Autoimmune Hyperthyroid)

Hashimotos (Autoimmune Hypothyroid)

Hyper-thyroidism

Hypo-thyroidism

IBS

IBD

PCOS

Seizures

Ulcers (Stomach)

Uterine Fibroids

*Other

If other, please specify:

Please log a food/drink diary as best you can for the last 3 days:

Please list all the supplements you take on a daily basis.

VITAMIN A

Poor immunity

Poor night vision

Macular degeneration (eye disease - blurred vision)

Dry mucus membranes (mouth, nose, eyelids, etc.)

Dry hair

Dry skin

Reoccurring infections

Asthma

VITAMIN C

Anemia

Bruising

Bleeding gums

Gum infections

Dental cavities

Lethargy

Dry hair or skin

Dry eyes

Tissue swelling

Hair loss

Pitting edema (fluid retension)

Delayed wound healing

VITAMIN D

Low sunlight exposure

Depression

Live far from the equator

Multiple bone fractures

Hair is painful to brush

Spongy feel of tibia (shin bone) under pressure

High body fat %

VITAMIN E

Brittle hair

Dry skin

Low immune tolerance (unresponsive immunity)

Low sperm count

Muscle weakness

Night blindness

Premature greying

Poor proprioception (spacial awareness)

VITAMIN K

Blood clotting defect

Easy bruising

Kidney disease

Kidney stones

Osteopenia (loss of bone mineral density)

Osteoporosis (severe loss of bone mineral density)

Soft tissue calcification

VITAMIN B1 (Thiamine)

Poor glucose tolerance

Energy/neurological improvements on low-carb diet

Tender muscles

Eye pain

Irritability

Poor concentration

Numb/tingly legs

Stomach pains

Constipation

Tingling hands or feet

Rapid heartbeat

Beriberi (a disease causing inflammation of the nerves and heart failure)

Wernicke's encephalopathy (a neurological disorder, typically from chronic alcoholism or persistent vomiting, and marked by mental confusion, abnormal eye movements, and unsteady gait)

Korsakoff's psychosis (a serious mental illness, typically the result of chronic alcoholism, characterized by disorientation and a tendency to invent explanations to cover a loss of memory of recent events)

VITAMIN B2 (Riboflavin)

Anxiety

Conjunctivitis

Fatigue

Migraines

Photophobia (eye discomfort in bright light)

Loss of appetite

Bloodshot eyes

Inflamed tongue

Cracked lips

Cracked corner of mouth

Mouth sores (Stomatitis)

Split nails

Oily hair

Light sensitivity

Seborrheic dermatitis (skin condition)

VITAMIN B3 (Niacin)

Anxiety

Diarrhoea

Dermatitis (skin irritation)

Dementia

Mouth sores (Stomatitis)

Poor appetite

Muscle weakness

Pellagra (dermatitis, diarrhoea, mental disturbance, often linked to over-dependence on maize as a staple food)

Unexplained weight-loss

VITAMIN B5 (Pantothenic Acid)

Anemia

Fatigue

Headaches

Insomnia

Intestinal disturbances

Numbness or painful burning / tingling in feet

Greying hair

Slow wound healing

Skin irritations

VITAMIN B6 (Pyridoxine)

Dry cracked lips

Swollen tongue

Mouth sores

Dermatitis (skin irritation)

Confusion (cognitive function)

Depression

Irritability

Nervousness

Sleeplessness

Nervous system disorders

VITAMIN B7 (Biotin)

Brittle nails

Dermatitis (skin irritation)

Depression

Eczema

Fatigue

Hair loss

Learning deficits

Slow metabolism

VITAMIN B9 (Folate)

Anemia

Diarrhoea

Cracking / redness of tongue / mouth

Leukopenia (a low white blood cell count)

Low birth weight or preterm delivery

Megaloblastic anemia (large red blood cells)

Muscle weakness

Thrombocytopenia (a low blood platelet count)

Unexplained weight-loss

VITAMIN B12 (Cobalamin)

Fatigue

Pernicious anemia (Autoimmune, Low B12, Large RBCs))

Neurological problem (tinging/numbness/degeneration)

Low stomach acid

Metformin use (Diabetes Type 2)

PPI use (proton pump inhibitor to decrease stomach acid production)

OCP use (oral contraceptive pills)

Vegetarian / vegan

MAGNESIUM

Anxiety

Arrhythmia (irregular heartbeat)

Cataracts

Cramps

Convulsions (involuntary muscle contractions)

Depression

Hearing loss

Hypertension

Irritability

Light sensitivity

Lowered immunity

Migraines / headaches

Muscle weakness

Pain hypersensitivity

Tinnitus (ringing in ear)

Tremors

CALCIUM

Alcohol consumption

Cardiovascular disease

Coronary artery disease

High protein intake

High salt intake

Hip fractures

Kidney stones

Lactose intolerance

Menopause

Osteoporosis (severe loss of bone mineral density)

Poorly regulated appetite

Vegetarian / veganism

PHOSPHORUS

Alcohol consumption

Anorexia

COPD (Chronic obstructive pulmonary disease)

Diabetic ketoacidosis (insufficient insulin)

Hyper-parathyroidism

Kidney stones

Kidney tubule defects

Muscle wasting

Rickets (soft/weak bones)

COPPER

Cold sensitivity

Headaches

Low energy availability

Low immune system

Low oxygen levels

Muscle weakness

Pale skin

Poor muscular contraction

Tremors

IRON

Anemia

Fatigue

Brittle nails

Dry hair and skin

Headaches

Heart palpitations

Pale skin

Pale flesh behind eyelids

Restless legs

Shortness of breath

Swollen / sore mouth / tongue

ZINC

Brittle nails

Decreased sense of smell or taste

Dermatitis (skin irritation)

Diarrhea

Lack of alertness

Low immunity

Low stomach acid

Lost desire to consume meat

Lowered libido

Slow wound healing

STOMACH (please tick all that apply)

Anemia

Bad breath

Burping after eating

Bloating after eating

Diarrhoea after eating

Passing gas shortly after meals

Frequent Hiccups

Upper abdominal bloating

History of bulimia

Heartburn or acid reflux

Frequent use of PPI's or antacids

Feel better if you skip meals

Previously diagnosed with H. Pylori

Difficulty digesting meat

Lost desire to consume meat

Discomfort when swallowing tablets

Brittle hair / hair loss

Fragile fingernails

Persistent Cough

Esophageal / diaphragm spasms

Rosacea (skin condition - redness of the cheeks, chin, nose...)

Vegetarianism / Veganism

GASTRIC OR DUODENAL ULCER HEALTH CHECK (please tick all that apply)

Heartburn when lying down or bending forward

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol or caffeine

Stomach pain, aching or burning 1-4 hours after eating

Previous or current diagnosis of H. Pylori

Temporary relief when eating food or drinking carbonated beverages

Digestive problems subside with rest and relaxation

Feeling hungry an hour or two after eating

Use of antacids / PPIs

PANCREATIC EXOCRINE FUNCTION (please tick all that apply)

Difficulty digesting roughage and fibre

Indigestion and fullness last 2-4 hours after eating

Pain, tenderness, soreness on the left side under the rib cage

Excessive passage of gas

Nausea and / or vomiting

Undigested food in stools

Foul smelling stool

Frequent loss of appetite

Systemic inflammation (chronic)

Obesity

Consistently elevated blood sugar

Low stomach acid

BILIARY AND GALLBLADDER (please tick all that apply)

Gallbladder removed

Dry ear canal

Dark ear wax

Headaches isolated to above the eyes

Yellowish cast to eyes

Yellowish cast to tongue

Floating stools

Foul smelling stool

Greasy stool

Clay coloured stool

Pain below the right side of the rib cage

Difficulty losing weight

Bitter metallic taste in the mouth, particularly in the morning

Burping & fishy taste after consuming fish oils

Unexplained itchy skin

Reddened palms

Dry or flaky skin

Dry hair

History of poor liver health

Gallstones

Heartburn

Get easily hungover if you drink alcohol

Mucosal film on the surface of water after passing stool

Pain between shoulder blades / around the upper right shoulder blade

Sensitive to chemicals / perfumes

Chronic fatigue or lethargy

Feel sluggish after consuming fats

Difficulty digesting high fat foods (Bloating, water retention, feeling full for an extended period of time)

HEPATIC BIOTRANSFORMATION (please tick all that apply)

Acne or unhealthy skin

Profuse smelling sweat

Excessive hair loss

Overall sense of bloating

Poor bowel function

Hormone imbalances

Bodily swelling for no reason

SMALL INTESTINES / MICROBIOME (please tick all that apply)

Bloating after eating (around belly button region)

Food allergies / sensitivities

Hay fever, congested sinuses or seasonal rashes

Diarrhoea or loose stools

Constipation

History of food poisoning or traveler's bug (even if once off)

History of UTI's (Urinary tract infections)

Dry eyes or mouth

Nerve pain

Pins and needles or sleeping limbs

Brittle hair / fingernails

Poor facial skin tone (e.g. looking washed out)

Poor exercise tolerance (e.g. bad muscle soreness)

Joint Pain / Neck Stiffness / Knee Pain / Finger Pain

Tooth or Mouth Sensitivity

LARGE INTESTINES / COLON (please tick all that apply)

Bloating lower down (below belly button)

Immediate bowel movements

Itchy Inner Ears

Anus or Vaginal itching

History of fungal or yeast infections (including athlete's foot)

Jock itch, dermatitis, or fungal rashes

Flakey skin on bottom of feet / heels

Excessively bad smelling gas

Frequently pass gas

Stomach cramps

Lower abdominal pain

Itchy Scalp / Dandruff

Anxiety or low motivation

Lethargy / fatigue

Feelings that your bowels do not completely empty

Clinically diagnosed with IBD / Ulcerative colitis, Crohn's, Celiac disease etc.

Blood in stool

Sugar Craving

Rectal bleeding

Blood after wiping

Black coloured stool

Passing stool brings on exhaustion

History of morphine use

Born via caesarean 'c' section

Coating on your tongue

Overly sensitive to alcohol

Taken more than 5 courses of antibiotics in your life

History of Roaccutane or other acne medication

History of chemotherapy

BACTERIA (please tick all that apply)

More than 3 bowel movements per day

Diarrhoea / loose stools

Constipation

Alternating stool consistency

Over 5 courses of antibiotics in lifetime

Used antibiotics within the past 2 years

History of binge eating disorder

High histamine

Pass gas daily

Bloat in the evening

Bloat after carbohydrates

Crave carbohydrates

Wake up multiple times during the night

Bacterial infections / UTIs (Urinary tract infections)

Intimate partner suffers from bacterial infection

Depression

Anxiety

Apathy

Unexplained brain fog

Swim in chlorinated pool >5 times per week / spa

PARASITES (please tick all that apply)

Unexplained weight loss

Fever

Anal itching

Wake up multiple times during the night

Insomnia

Nightmares

Night sweats

Teeth grinding

Muscle aches

Joint pain

Chronic fatigue

Constantly hungry

Intense cravings

Presence of worm in stool

Excess mucus in stool

Cramps

Intrusive thoughts

Symptoms worsen around the full moon

History of food poisoning

Traveler's diarrhoea

Anemia

Biting nails

Unexplained brain fog

Depression

Anxiety

Apathy

Dry eyes

Red eyes

Itchy skin

CANDIDA (please tick all that apply)

Oral thrush

White patches in the mouth & tongue

Red spots on tongue

Cottony feeling in the mouth

Yeast infections

Vaginal itching

Jock itch

Diarrhoea

Cramps

Nausea

Gas

Bloating

Vision changes

Headaches

Feel worse after sugar

Brain fog

UTI's (Urinary tract infections)

Chronic sinusitis

Toenail fungus

Athletes foot

Skin fungus

Joint pain

Low mood

Recurrent herpes outbreaks

INTESTINAL PERMEABILITY (please tick all that apply)

Increasing frequency of food reactions

Unpredictable food reactions

Aches, pains & swelling throughout the body

Frequent bloating after eating

Long-term injuries which won't heal

Sensitivity to gluten

Clinically diagnosed with IBD / Ulcerative colitis, Crohn's, Celiac disease etc.

Pain on the left side of the rib cage

MYCOTOXINS (please tick all that apply)

Fatigue

Muscle weakness

Muscle aches

Cramps

Unusual numbness

Ice pick pains

Headaches

Light sensitivity

Tearing of the eyes

Blurred vision

Red eyes

Sinus issues

Persistent tickly cough

Shortness of breath

Acute, short, sharp abdominal pains

Diarrhoea

Joint pain

Cognitive issues

Poor concentration

Profuse sweat

Disorientation

Apathy

Skin sensitivity

Loss of appetite

Increased frequency of static shocks

Tingling

Excessive urination

Tremors

Metalic taste

Low temperature

Water retention

Mould exposure in home

Feel worse after coffee

Air conditioning constantly on with no ventilation

Lived in Asia

Lived / worked in water damaged building

ENDOTOXEMIA HEALTH CHECK

Have not felt the same after antibiotic

NAFLD (Non-alcoholic fatty liver disease)

Old injuries flare up during anti-microbial phase

Constipation

Haemorrhoids

Blood in stool

Blood after wiping

Extended Herxheimer reactions over 7 days (flu-like symptoms including headache, joint and muscle pain, body aches, sore throat, general malaise, sweating, chills, nausea, or other symptoms).

STOOL ANALYSIS (please tick your usual consistency)

Type 1 - Separate hard lumps / "rabbit droppings"

Type 2 - Lumps compacted together

Type 3 - Log with cracks in the surface

Type 4 - Smooth log

Type 5 - Soft blobs with clear-cut edges

Type 6 - Mushy consistency with ragged-edges

Type 7 - Liquid consistency with no solid pieces

BLOOD SUGAR (please tick all that apply)

Irritable if a meal is missed

Shaky if a meal is missed

Unable to train for long period of time

Tired or weak when a meal is missed / or following a low-carb diet

Lightheaded if a meal is missed / or following a low-carb diet

Unable to follow a low-carb diet or Intermittent fasting

Eating relieves fatigue

History of diabetes in family

Tired immediately after eating

Frequent urination

Constant thirst

Numbness in toes

ADRENAL FUNCTION (please tick all that apply)

Difficulty falling asleep

Difficulty waking up or getting going in the morning

History of high or low blood pressure

Grinding teeth at night

Chronic back or knee pain

Become dizzy when standing suddenly

Crave salty foods

Emotionally traumatic events in the past

KIDNEY FUNCTION (please tick all that apply)

Urination problem

Pain in lower back

Swelling around the ankles

Excessive thirst

You drink less than 2 liters of water a day

Clear urine

You drink alcohol more than once a month

You take synthetic recreational drugs

HYPOTHYROIDISM (please tick all that apply)

Poor short term memory

Struggle working under pressure

Losing the outer third of the eyebrow

Mercury fillings

Enlarged eyes

Difficulty losing weight

Difficulty waking up or getting going in the morning

Stiff muscles in the morning

Weakened muscles

Easily fatigued or sleepy during the day

Constipation

Hair loss

Diagnosed with thyroid condition

Consistently low mood

Not using a fluoride water filter for drinking

Consume large fish more than twice per week (salmon, tuna, shark etc.)

Pale skin

Dry skin

Brittle hair and / or nails

Cold hands and / or feet

Sensitive to cold temperatures

Muscle cramps

Fertility issues

Menstrual irregularities

Water retention

History of Epstein Barr Virus

Currently on the birth control pill

Chronic dieting

HYPERTHYROIDISM (please tick all that apply)

Heat intolerance

Nervousness

Hard to put on weight or build muscle

Warm moist skin

Trembling hands

Heart palpitations

Nausea

Fast heart rate

Anxiety

Insomnia

Night sweats

Breathlessness

Increased bowel movements

Loose stools

Light or absent menstrual cycle

Use of thyroid medication

Hair loss

Women's Health (skip if male)

HIGH PROGESTERONE (please tick all that apply)

Breast discomfort

Insomnia

Drowsiness

Slight dizziness

Feeling of being drunk or spinning

Heaviness of the extremities

Fatigue

Feeling tense or irritable

Nausea

Change in appetite

Water retention

Weight gain

Acne

LOW PROGESTERONE (please tick all that apply)

Insomnia

Anxiety

Menstrual spotting

Amenorrhea (loss of period)

Oligomenorrhea (infrequent periods)

Highly frequent periods

PMS with early onset

Endometriosis

Fibrocystic breast tissue

Water retention

Women's Health (skip if male)

HIGH ESTROGEN (please tick all that apply)

Endometriosis

Heavy menstrual cycle

Uterine fibroids

Fibrocystic breasts

Excessive mental chatter, dwell on things longer or harder to switch off from things

Exaggerated stress response

Hold onto fat easily

Store fat or hold onto water retention easily on the glutes

Store fat or hold onto water retention easily on the thighs

Store fat or hold onto water retention easily on the back of the arms

Store fat or hold onto water retention easily on the hips

Store fat or hold onto water retention easily on the lower abdomen

Store fat or hold onto water retention easily on the chest

Crave sugar

Crave chocolate

Mood swings

Headaches

Poor circulation (including varicose veins)

Easy bruising

Bloating

Intolerance to heat

Sensitivity to caffeine

Histamine issues

Poor motility

LOW ESTROGEN (please tick all that apply)

Hot flushes

Night sweats

Peri-menopausal / post-menopausal

PCOS

Absence of menstrual cycle

Incontinence

Frequent UTI infections

Brain fog

Lack of motivation

Forgetfulness

Insomnia

Gaining fat around the mid-section

Poor bone mineral density / osteoporosis

Loss of fat and muscle on the lower body

Feel better in week 2 of the menstrual cycle

Facial hair

Thinning hair

Loss of breast fullness / sagging

Vaginal dryness

Menstrual flow is less than 3 days

Painful intercourse

Feel better after a glass of red wine

Women's Health (skip if male)

LOW TESTOSTERONE (females) (please tick all that apply)

Loss of libido

Impaired sexual function

Increased aches and pains

Incontinence

Thinning skin

Thin tissue of the vulva and labia

Loss of muscle tone

Wrinkled skin

Hot flashes

Depression

Lack of drive and confidence

Lichen Sclerosus (white, thickened and crinkly skin)

PCOS (please tick all that apply)

Excess hair growth

Male pattern hair loss on head

Weight gain

Acne

Irregular cycles

Anovulatory cycles (absence of ovulation)

Anxiety

Sub-fertility

IBS

Food tolerances

Sugar cravings

Insulin resistance

ENDOMETRIOSIS (please tick all that apply)

Heavy bleeding

Painful periods

Ovulation pain

IBS

Nickel allergies

Painful intercourse

Blood clots

Histamine intolerance

Long follicular phase

Short luteal phase

Fertility challenges

Estrogen dominant profile

Men's Health (skip if female)

LOW TESTOSTERONE (please tick all that apply)

Low self-confidence

Incontinence

Hot flashes

Dry thinning hair

Thinning skin

Thin lips

Decreased libido

Decrease in spontaneous morning erections

Decrease in fullness of erection

Decrease in maintaining erections

Spells of mental fatigue

Inability to concentrate

Difficulty in making decisions

Episodes of depression

Excessive muscle soreness

Decrease in physical stamina

Unexplained weight gain

Increased fat gain around chest (man boobs) and hips

Increased sweating

More emotional than in the past

Previous use of anabolic steroids

Plant based diet

Chronic dieting / low fat intake

Use of aspirin

LYMPHATIC SYSTEM (please tick all that apply)

Swollen lymph glands

Feeling stiff after sitting too long

Feeling stiff in the morning

Imbalanced body temperature from one side to another

Reoccurring infections of the ears, nose and / or throat

Cold sores

Low immune system

Boils & spots

Slow wound healing

Allergic symptoms (Discharge from the eyes, puffiness under eyes, excessive mucosa production)

Frequent headaches

Tattoos

ENVIRONMENTAL FACTORS (please tick all that apply)

You lived or worked in buildings with mould

You do NOT use a water filter for drinking

There is a Wi-Fi router in your bedroom

You have mercury fillings

You do NOT stand barefoot outdoors or on cement daily

You live next to power lines or industrial plants

You work with chemicals or petroleum (e.g. hairdresser, at a factory, gas station etc.)

SLEEP (please tick all that apply)

Sleep less than 7 hours per night

Sleep more than 9 hours per night

Go to sleep after 10:30 PM

Wake during sleep

Travel across time zones more than once a month

Work night shifts

Use electronic screens within 1 hour of bed

Use polyester bedsheets

Poor air quality in bedroom

Consume caffeine after 3PM

Train after 5PM

Eat within 2 hours of sleeping

MASTICATION (please tick all that apply)

TMJ issues

Jaws clicks or crunches when chewing

Chew predominantly on one side

Pain in jaw

ORAL TOLERANCE (please tick all that apply)

Last person to finish meals

Mouth does not reflect light

Bubbles near the sub-mandibular glands (below tongue)

High fibre food challenging to eat

Poorly controlled diabetes

Use of prescribed medicines, Xanax or Zoloft

Increasing frequency of food reactions

Unpredictable food reactions

MOUTH HEALTH (please tick all that apply)

White patches

Bleeding gums

VAGUS NERVE FUNCTION (please tick all that apply)

Zero visible soft palate contraction

Fatigued soft palate contraction

Lack of gag reflex

Hypersensitive gag reflex

Inability to swallow supplements

Suffered from head trauma (whiplash etc.)

HRV less than 70

Delayed pupil response

Lack of smell

Dysautonomia (ANS disorder)

Globus pharyngeus (lump in throat)

Suffer from either Gastroparesis or Achalasia (slow passing of food/liquid through GI tract)

PSYCHO-EMOTIONAL STRESS (please tick all that apply)

Perfectionism

Competitiveness

Self doubt

Lack of self-worth

Lack of self-identity

Lack of direction

Distrust

Trauma

Anxiety

Irrational phobias

Lack of social interaction

Lack of support

Anger

Heartbreak

Economic struggles

Body image issues

PHYSIOLOGICAL STRESS (please tick all that apply)

Parasites

Gut Dysbiosis

Mould exposure / fungal infection

Intestinal permeability / Leaky gut

Endotoxemia (endogenous toxins)

Viruses

Dyslipidemia (imbalance of lipids)

High toxic load

Andropause / menopause

Hypothyroidism

Diabetes / Insulin resistance

Nutrient deficiencies

Inflammation

Lack of sunlight

Obesity

Liver / kidney dysfunction

PHYSICAL STRESS (please tick all that apply)

Excessive DOMS (Delayed onset muscle soreness)

High training volume (too much exercise)

Poor posture

Injury

Lack of aerobic capacity (easily tired/dizzy/sick from moderate exercise)

Restricted nasal breathing (mouth breather)

Constipation

Stagnant / insufficient movement

DIETARY STRESS (please tick all that apply)

Chronic overconsumption

Chronic underconsumption

Excessive stimulants (caffeine)

Dehydration

Trigger foods

Blood sugar dysregulation

Poor relationship with food

Limited food diversity

LIFESTYLE STRESS (please tick all that apply)

Loss of a loved one

Loss of job

Changing job

Moving house

Divorce / break-up

Travel

School

Lockdown

HYPERFUNCTION (please tick all that apply)

Wake up before alarm clock

Crave sugar

Central obesity

Shaky between meals

Irritable

Easily angered / short-fused

Amenorrhea (loss of menstrual cycle)

Hypertension / high blood pressure

Grind teeth

Frequent headaches

Crave carbohydrates after midday / especially in the evening

Wake up multiple times during the night

Takes longer than 30 minutes to fall asleep

Thoughts racing through head

Sweat easily

Tight muscles

HYPOFUNCTION (please tick all that apply)

Use snooze button / set several alarms

Require coffee in the mornings / feel tired without coffee

Desire to nap midday

Afternoon crash in energy

Chronic weakness

Fatigue

Decrease stamina / poor exercise tolerance

Decreased libido / Amenorrhea (loss of menstrual cycle)

Crave salt

Postural dizziness

Muscle or joint pain / excessive DOMS

Skin tender to apply pressure

Bruise easily

Hypotension / low blood pressure

Emotionally flat

Poor concentration & memory

Feel overcommitted in daily life

Reclusive behaviour

Hypermobile joints

Medial bilateral knee pain

NAILS (please tick all that apply)

Vertical ridges

Brittle nails

Nail biting

Nails splitting

Hangnails (torn skin at base of nails)

Discolouration to nails

Thin dark band near the bottom of the finger nail

Thick transverse lines which disappear under pressure

Curve over the fingertip

Curve backwards away from the fingertip

NOSE (please tick all that apply)

Stuffy

Sneezing

Lost sense of smell

Visible small red vessels

EARS (please tick all that apply)

Ear infection

Deafness

Dry patches behind the ear

Ear piercings

EYES (please tick all that apply)

Dark circles under the eyes

Swollen / puffy

Lymphatic rosary (white cloud around edge of iris)

Chronic red eyes

Pale flesh behind the eye lid

Cataract (cloudy lens)

Delayed pupil dilation

Yellow spots and pimples under eye

SKIN (please tick all that apply)

Eczema, dermatitis, psoriasis

Yellow tone

Rashes

Brown / red tint on shins

Itching

Red nodules on triceps

Red tone

Red, yellow or purple mottling on palms

Easy bruising

Thick skin (tough to pinch)

Dry

Cracked heels

TONGUE (please tick all that apply)

Yellow cast

Quivering

Mucosal film

Lateral serrations

Red spots

Glossitis (tongue inflammation)

HAIR (please tick all that apply)

Painful to brush

Dandruff

Dull & flat

Premature greying

Hirsutism (excess hair around mouth & chin - female)

Male pattern baldness

Losing the outer third of eyebrow

Hair falling out

Alopecia