First Name *

Last Name *

Email *

Phone *

What is your zip code? *

Digestive Tract

Nausea or Vomiting *

0

1

2

3

4

Diarrhea *

0

1

2

3

4

Constipation *

0

1

2

3

4

Bloated Feeling *

0

1

2

3

4

Belching or Passing Gas *

0

1

2

3

4

Intestinal/Stomach Pain *

0

1

2

3

4

Heartburn *

0

1

2

3

4

Ears

Itchy Ears *

0

1

2

3

4

Earaches, Ear Infections *

0

1

2

3

4

Drainage from the Ear *

0

1

2

3

4

Ringing in Ears / Hearing Loss *

0

1

2

3

4

Emotions

Mood Swings *

0

1

2

3

4

Anxiety, Fear, or Nervousness *

0

1

2

3

4

Anger, Irritability, Aggressiveness *

0

1

2

3

4

Depression *

0

1

2

3

4

Engery/Activity

Fatigue, Sluggishness *

0

1

2

3

4

Apathy, Lethargy *

0

1

2

3

4

Hyperactivity *

0

1

2

3

4

Restlessness *

0

1

2

3

4

Eyes

Watery or Itchy Eyes *

0

1

2

3

4

Swollen, reddened, or sticky eyelids *

0

1

2

3

4

Bags or dark circles under eyes *

0

1

2

3

4

Blurred or Tunnel Vision *

0

1

2

3

4

Head

Headaches *

0

1

2

3

4

Faintness *

0

1

2

3

4

Dizziness *

0

1

2

3

4

Insomnia *

0

1

2

3

4

Heart

Irregular or Skipped Heart Beats *

0

1

2

3

4

Rapid or Pounding Heartbeat *

0

1

2

3

4

Chestpain *

0

1

2

3

4

Lungs

Chest Congestion *

0

1

2

3

4

Asthma, bronchitis *

0

1

2

3

4

Shortness of Breath *

0

1

2

3

4

Difficulty Swallowing *

0

1

2

3

4

Difficulty Breathing *

0

1

2

3

4

Mind

Poor memory *

0

1

2

3

4

Confusion, Poor Comprehension *

0

1

2

3

4

Poor Concentration *

0

1

2

3

4

Poor Physical Coordination *

0

1

2

3

4

Difficulty in Making Decisions *

0

1

2

3

4

Stuttering or Stammering *

0

1

2

3

4

Learning Disabilities *

0

1

2

3

4

Slurred Speech *

0

1

2

3

4

Mouth/Throat

Chronic Coughing *

0

1

2

3

4

Gagging, Frequent Need to Clear Throat *

0

1

2

3

4

Sore throat, Horseness, Loss of Voice *

0

1

2

3

4

Swollen/discolored tongue, gum, lips *

0

1

2

3

4

Canker Sores *

0

1

2

3

4

Nose

Stuffy Nose *

0

1

2

3

4

Sinus Problems *

0

1

2

3

4

Hay Fever *

0

1

2

3

4

Sneezing Attacks *

0

1

2

3

4

Excessive Mucus Formation *

0

1

2

3

4

Skin

Acne *

0

1

2

3

4

Hives, Rashes, or Dry Skin *

0

1

2

3

4

Hair Loss *

0

1

2

3

4

Flushing or Hot Flashes *

0

1

2

3

4

Excessive Sweating *

0

1

2

3

4

Weight

Binge eating/drinking *

0

1

2

3

4

Craving certain foods *

0

1

2

3

4

Excessive Weight *

0

1

2

3

4

Compulsive Eating *

0

1

2

3

4

Water Retention *

0

1

2

3

4

Underweight *

0

1

2

3

4

Joints/Muscles

Pain or aches in joints *

0

1

2

3

4

Arthritis *

0

1

2

3

4

Stiffness or limitation of movement *

0

1

2

3

4

Pain or aches in muscles *

0

1

2

3

4

Feeling of weakness or tiredness *

0

1

2

3

4

Other

Frequent illness *

0

1

2

3

4

Frequent or urgent urination *

0

1

2

3

4

Genital itch or discharge *

0

1

2

3

4

MSQ Score

I understand that Grace Optimal Wellness is not contracted with any health insurance companies.

Yes, I understand that Grace Optimal Wellness is not contracted with any health insurance companies.