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There are many causes for each symptom listed below. One of the most common causes is the presence of parasites. Please circle the appropriate number next to each question.

A= symptom never occurs

B= symptom occurs occasionally

C= symptom occurs often

D= symptom occurs most of the time

 
 
Name
A
B
C
D

1.Chronic fatigue for no apparent reason
0
1
2
3
2.Swollen or achy joints
0
1
2
3
3.Increased appetite,hungry after meals
0
1
2
3
4.Eat out at restaurants
0
1
2
3
5.Nervous or irritable
0
1
2
3
6.Restless sleep/teeth grinding while asleep
0
1
2
3
7.Night sweats
0
1
2
3
8.Blurry, unclear vision
0
1
2
3
9.Fevers of unknown origin
0
1
2
3
10.Frequent colds, flu, sore throats
0
1
2
3
11.Recurrent feelings of unwellness
0
1
2
3
12.Constipation
0
1
2
3
13.Diarrhea alternating with constipation
0
1
2
3
14.Thinning or loss of hair
0
1
2
3
15.Allergies, food sensitivities
0
2
4
6
16.Irritable bowel, irregular bowel
0
2
4
6
17.Rectal, anal itching
0
2
4
6
18.Bloating or gas
0
2
4
6
19.Abdominal or liver pain/cramps
0
2
4
6
20.Mucus in nose that is moist or encrusted
0
2
3
4
21.Dark circles under the eyes
0
2
3
4
22.Bowel urgency
0
2
3
4
23.Skin problems, rashes, hives, itchy skin
0
2
3
4
24.Vertical wrinkles around mouth
0
2
3
4
25.Kiss pets, allow pets to lick your face
0
2
3
4
26.Go barefoot outside the home
0
2
3
4
27.Travel in 3rd world countries
0
2
3
4
28.Eat lightly cooked pork/ salmon products
0
2
3
4
29.Eat sushi, sashimi
0
2
3
4
30.Swim in creeks, rivers, lakes
0
2
3
4
31.History of parasitic infection
0
2
3
4
32.Loose stools or diarrhea
0
2
3
4
33.Pale, anemic or yellowish skin
0
2
3
4
34.Foul-smelling stools
0
2
3
4
35.Low back or kidney pain
0
2
3
4
36.Indigestion, malabsorption
0
2
3
4
 
 
 
 
Total (A + B + C + D ):
0
 
 
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