DinaKhader.com

   


Health Profile

This form is for new clients of Dina Khader prior to a first consultation.  Please do not submit this form unless you have been requested to do so.  Be sure to enter your name below.
Your Name:
Rate each of the following symptoms based upon your typical health profile for the past 30 days.
Point Scale:
0 - Never or almost never have the symptom
1 - Occasionally have it, the effect is not severe
2 - Occasionally have it, the effect is severe
3 - Frequently have it, the effect is not severe
4 - Frequently have it, the effect is severe

When you've filled in a rating for all symptoms, be sure to hit the Calculate Totals button to fill in the totals.  They are not manually entered.  Once totals have been calculated, hit submit to send the form to our office.
Head
Headaches
Faintness
Dizziness
Insomnia
Head Total
Eyes
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Eyes Total
Ears
Itchy Ears
Earaches, Infections
Drainage
Ringing, Hearing Loss
Ears Total
Nose
Stuffy Nose
Sinus Problems
Hay Fever
Sneezing Attacks
Excessive Mucus
Nose Total
Mouth & Throat
Chronic coughing
Gagging, Frequent Need To Clear Throat
Sore Throat, Loss of Voice
Swollen or Discolored Tongue, Gums or Lips
Canker Sores
Mouth & Throat Total
Skin
Acne
Hives, Rashes, Dry Skin
Hair Loss
Flushing, Hot Flashes
Excessive Sweating
Skin Total
Heart
Irregular or Skipped Beat
Rapid or Pounding Beat
Chest Pain
Heart Total
Lungs
Chest Congestion
Asthma, Bronchitis
Shortness of Breath
Difficulty Breathing
Lungs Total
Digestive Tract
Nausea, Vomitting
Diarrhea
Constipation
Bloated Feeling
Belching, Gas
Heartburn
Intestinal/Stomach Pain
Digestive Tract Total
Joints & Muscles
Pain or Aches in Joints
Arthritis
Stiffness, Limited Movement
Muscle Pain/Aches
Weakness, Tired Muscles
Joint & Muscle Total
Weight
Binge Eating/Drinking
Cravings
Excessive Weight
Compulsive Eating
Water Retention
Underweight
Weight Total
Energy/Activity
Fatigue
Apathy, Lethargy
Hyperactivity
Restlessness
Energy/Activity Total
Mind
Poor Memory
Confusion, Poor Comprehension
Poor Concentration
Poor Coordination
Difficulty Making Decisions
Stuttering, Stammering
Slurred Speech
Learning Disability
Mind Total
Emotions
Mood Swings
Anxiety, Fear, Nervousness
Anger, Irritability
Depression
Emotions Total
Other
Frequently Ill
Frequent or Urgent Urination
Gential Itch or Discharge
Other Total
Grand Total