Name
*
First Name
Last Name
Date of birth
MM
DD
YYYY
Year of Birth - Mom
MM
DD
YYYY
Year of Birth - Dad
MM
DD
YYYY
Phone
(###)
###
####
Work Phone
(###)
###
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Email
*
ViralScore™ Referred by
Do you currently take vitamins or other supplements?
If yes, please list:
Please check any of your following conditions/medications or medical procedures you are currently taking or have done up to today's date:
Family History (Please check any that applies)
Other - please list
Childhood History (Please check any that applies)
Other - please list
Number of glasses of water daily
Choose type or types
Food intake last 24 hours - please list
Sugar Types/Day, Artificial/Natural
Number of times/Smoke/Day
Number of amalgam/fillings
Number of known allergies
Number of major infections/past
Number Alcohol Drinks/Day
Number of caffeine/products
Number of major injuries/Past
How many pounds overweight
Personal Stress - work (1-10)
Personal Stress - home (1-10)
Cosmetic types used - Please list
The following information is provided to this facility for nutritional information. The information being sought is of a nutritional nature and not a medical diagnosis, treatment, disease prevention or health assessment. I hereby certify that I am not an employer, agent, or otherwise affiliated with the Federal Drug Administration, Health Canada, or a related agency. I further understand: According to the Federal Food, Drug and Cosmetic act, as amended, Section 201 (g) (I), the term "Drug" is defined to meanL Articles intended for the use in the DIAGNOSIS, CURE, MITIGATION or PREVENTION of disease. In other words, to "say" that vitamin, mineral, trace or amino acids will have any effect on disease or symptoms thereof, that a particular nutrient then becomes a DRUG under the law as written. Therefore, any suggested nutrition is not intended as primary therapy for any disease or symptom, but is provided safely to upgrade the quality of foods delivered through the diet. By providing information you are aware that you are consenting for information to be used under the name ViralScore™ Nutritional Self-Evaluation. Information provided will be used for statistical gathering of data purposes only. No confidential information obtained will be used for any other purpose other than the ViralScore™ program.
THYROID SYMPTOM SURVEY
Symptom Rating:
More tired and sluggish than normal
Drier hair and skin than normal
Sleep more than usual
Weaker Muscles
Colder than others
Muscles cramp more than usual
Poorer memory
More depressed
Slower thinking
Eyes are more puffy
Math is more difficult
Hoarser or deeper voice
Constipated more often
Coarser hair
Puffy hands and feet
Unsteady when walking
Gain weight easily
Outer third of eyebrow thin
Next 3 questions are for menstruating females only
Menses more irregular
Heavier Menses
TOTAL
HYPER- SYMPTOMS
Palpitations
Insomnia (don't sleep well)
Tremors (shaking)
Increased sweating
Brittle nails
Loss of appetite
TOTAL
GRAND TOTAL (0-9 Unlikely you are hypothyroid, 10-19 Mild hypothyroidism, 20-29 - Moderate hypothyroidism, 30+ Severe hypothyroidism
Acidosis - Chermical/Heavy metal toxicity Self Evaluation / Assessment
Psychological (Liver, Kidneys, Bladder
Oral Cavity
Digestive / immune & Gut dysfunction
Cardiovascular
Inflammatory and immunological (Lungs, Large intestine)
Other problems
NUTRITIONAL SELF/EVALUATION
Please list foods and fluids consumed in the last 24 hours:
List your top 3 health concerns
What areas of your body are of concern as far as the main pain:
What areas of your body are of concern as far as the secondary pain:
What areas of your body are of concern as far as numbness:
What areas of your body are of concern as far as pins and needles:
What areas of your body are of concern as far as skin lesions / scarring:
Do you know what triggered the pain?
Does anything relieve it?
Does anything aggravate it?
Has it changed since it began?
Have you had any other treatments?