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Initial Questionnaire: Please print out, fill in and bring to your consultation.
(adapted from "Patient Metabolic Screening
Questionnaire" F.I.T Sales P/L www.fit.net.au)
Dr David Bird, Chronic fatigue Clinic, 03 - 5963 7000, Goolmangar, Vic, www.burnoutsolutions.com.au email birddavid777@yahoo.com
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Digestive ___ Nausea or vomiting ___ Diarrhea ___ Constipation ___ Bloating ___ Belching, passing gas ___ Heartburn ___ Intestinal/stomach pain ___ TOTAL |
Mind ___ Poor memory or recall ___ Confusion, poor comprehension ___ Reduced concentration ___ Clumsiness ___ Difficult to make decisions ___ Stuttering, stammering, slurring ___ Mind goes blank, cannot find words ___ TOTAL |
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Ears and eyes ___ Itchy or painful ears ___ Ringing in ears, hearing loss ___ Watery or itchy eyes ___ Swollen, red or sticky eyelids ___ Bags or dark circles under eyes ___ Visual disturbance ___ TOTAL |
Emotions ___ Mood swings ___ Anxiety/worry ___ Panic attacks ___ Anger, irritability ___ Depression ___ Insomnia ___ TOTAL |
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Head and nose ___ Headache ___ Dizziness/faintness ___ Blocked nose, sinus problems ___ Excessive mucous ___ TOTAL |
Energy/Muscles and joints ___ Fatigue ___ Need to sleep in the day ___ Muscle ache or pain ___ Joint pain or stiffness ___ TOTAL |
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Heart and lungs ___ Chest pain ___ Irregular heartbeat or skipped beats ___ Rapid or pounding heartbeat ___ Chest congestion ___ Difficulty breathing/shortness of breath ___ TOTAL |
Skin ___ Acne ___ Hives, rash, dry skin ___ Hair loss ___ Hot flushes ___ Excessive sweating ___ TOTAL |
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Weight/Other ___ Binge eating/drinking ___ Craving certain foods ___ Compulsive eating ___ Frequent or urgent urination ___ Genital itch or discharge ___ TOTAL |
Mouth/throat ___ Coughing ___ Gagging, need to clear throat ___ Sore throat, hoarseness, voice loss ___ Swollen or discoloured tongue or lips ___ Mouth ulcers or canker sores ___ TOTAL |
| ___ TOTAL COLUMN A |
___ TOTAL COLUMN B ___ TOTAL COLUMN A ___ GRAND TOTAL Date.......... |