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HTMA Symptoms Form
Your Name
(required)
Email
(valid email required)
Please check each box of symptoms that presently describe you.
Joint Pain
Joint Stiffness
Arthritis, Osteo
Arthritis, Rheumatoid
Muscle Pain
Muscle Cramps
Bursitis
Fractures
Osteoporosis
Gout
Sweet Cravings
Sugar Reactions
Irritable before meals
Can't skip meals
Hypoglycemia
Crave Starches
Fat cravings
Other Food Cravings
Food Allergies
Excessive Hunger
No hunger
Diabetes
Rapid Heart Beat
Skipped Heart Beats
Heart Palpitations
Heart Attack
Poor circulation
Dizziness
Low Blood Pressure
High Blood Pressure
Angina
Arteriosclerosis
High Cholesterol
High Triglycerides
Cough
Brochitis
Asthma
Post-nasal Drip
Sinus Congestion
Allergies
Emphysema
Fatigue
Hypothyroidism
Low Body Temperature
Cold in Winter
Dry Skin
Tend to Gain Weight
Hyperthyroidism
Acne
Eczema
Fungal Infections/ Candida
Psoriasis
Hives
Hair Loss
Slow Wound Healing
Cataracts
Glaucoma
Meniere's Disease
Tooth Decay
Excessive Plaque on Teeth
Gum Disease
Eye Conditions
Get infections Easily
Epstein-Barr Virus
Tumour/ Cancer
Multiple Sclerosis
Parkinson's Disease
Scleroderma
Anger
Anxiety
Bipolar Disorder
Brain Fog
Confusion
Depression
Irritability
Mind Races
Mood Swings
Obsessive Compulsive
Panic Attacks
Poor Memory
Suicidal thoughts
Schizophrenia
Trouble sleeping
Autism
Attention Deficit
Hyperkinesis
Dyslexia
Seizures
Learning Disability
Mental Retardation
Delayed Development
Bladder Infections
Kidney Infections
Trouble Urinating
Frequent Urination
Painful Urination
Kidney Stones
Water Retention
Sinus Headaches
Tension Headaches
Migraine Headaches
Neuritis
Constipation
Diarrhea
Intestinal Gas
Bloating
Heartburn
Ulcer
Stomach Pain
Colitis
Gall Stones
Fissures
Hemorrhoids
Cirrhosis
Diverticulitis
Tend to Weight Gain
Tend to Lose Weight
Anemia
Easy Bruising
Abuse
Drug Addiction
Alcoholism
Smoking
Women:
Premenstrual Syndrome
Water Retention
Cramps
No Menstruation
Heavy Periods
Light Periods
Irregular Periods
Ovarian Cysts
Fibroid Tumours
Abnormal Pap Smear
Menopause
Fibrocystic Breasts
Breast Tumours
Yeast Infections
Hot Flushes
Men:
Prostate Problems
Impotence
Infertility
Other symptoms:
Out of the symptoms that you have selected above, please list the ones that are the MOST important.
Disclaimer: Nutritional Balancing is a means t reduce stress and is not intended as diagnosis, treatment or prescription for any condition or disease. (Sari Young, Naturopath)
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