Name*

Your E-mail Address*

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.