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NCS Questionnaire

Name* :
Email* :
Mark the intensity of the following symptoms on a scale of 1-3. 1; mild, 2; moderate, 3; severe. Use approximate date for "first observed" and use N/A, occasionally, often, and always for frequency
Symptoms
Intensity
First observed
Frequency
Skin:
Open Lesions
Oozing Lesions
Painful Sores
Itchy Pimples
Tracks
Elevated Ripples
Elevated Veins
Bumps
Skin Peeling
Scalp sores
Fibers
Springtails
Fungus
Nervous:
Skin Irritation
Pin prick sensations
Crawling sensations
Burning sensations
Movement sensations
Red hot face
Memory loss
Brain fog
Poor concentration
Body tremors
Vision problems
Other organ systems:
Endocarditis
Heart palpitations
High blood pressure
Flu-like symptoms
Intestinal abnnormalties
Bowel disturbances
Parasites
Vomiting
Kidney problems
Respiratory disturbances
Coughing
Tight chest
Swelling
Joint pain
Muscular pain
Liver dysfunction
Arthritic symptoms
Oral abnormalties:
Inflammed gum tissue
Gray gum tissue
Mucoid secretions
Dental decay
Abscesses
Teeth gray
Painful roots
Thrush around lips
Sensitivity to:
Metals
Sulfa
Zinc
Aspirin
Penicillin
Light
Noise
Electro-magnetic fields
Mold
Humidity
General:
Fatigue
Nausea
Insomnia
Compromised immune
Psychological trauma
Night fever/sweats
Weight loss
Please list any additional symptoms that you are having here:
Previous diagnosis and dates:
Dental history:
Previous treatment and impact:
Drug use and additional notes:
Do you have any implants or other foreign objects in your body?:
If you have scored moderate or severe in the categories of movement, crawling, or pin-prick sensations, you are probably a genuine case of NCS. If you have scored moderate or severe in other neurologial, skin, organ system, or general caterories, this will represent added confirmation of your NCS status. Keep a copy of this questionaire for your records, and another copy for PCI should you have need for a follow up.
This questionaire is legally protected: patent number 13367629 pending. Any redistribution of material in the protocol without written consent of PCI is illegal.
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