Synergy Health & Wellness

Heidilyndaker.com

/ 202- 750-7365

Answer the following questions on a frequency scale of 0-3
(0 = Occurs Never or Rarely 3= Occurs Often or Always)
Please take your time and be honest; the more accurate you are the better we will understand which systems are a priority for you

Heidilyndaker.com

/ 202- 750-7365

Category 1 Total%
Standing quickly causes faintness or dizziness / 0 / 1 / 2 / 3 / Urine always light colored / 0 / 1 / 2 / 3
Reccurent flushing or blushing / 0 / 1 / 2 / 3 / Dull ache or dribble after urination / 0 / 1 / 2 / 3
Moderate low blood pressure / 0 / 1 / 2 / 3 / Frequent bladder infections / 0 / 1 / 2 / 3
Frequent thirst / 0 / 1 / 2 / 3 / Frequent or urgent urination, small amounts / 0 / 1 / 2 / 3
Craving for salt / 0 / 1 / 2 / 3 / Mucus in urine / 0 / 1 / 2 / 3
Category 2 Total %
Standing quickly makes pulse roar in ears / 0 / 1 / 2 / 3 / Moderate high blood pressure / 0 / 1 / 2 / 3
Frequent water retention / 0 / 1 / 2 / 3 / Infrequent urination, copious urine / 0 / 1 / 2 / 3
Urine usually dark / 0 / 1 / 2 / 3
Category 3 Total %
Fast, Light Pulse / 0 / 1 / 2 / 3 / Hypertension, not responding to diuretics / 0 / 1 / 2 / 3
Cold bodied / 0 / 1 / 2 / 3 / Injuries/Cold heal slowly / 0 / 1 / 2 / 3
Sometimes dizzy or faint / 0 / 1 / 2 / 3 / Cold hands and feet / 0 / 1 / 2 / 3
Hands cold, clammy, or dry / 0 / 1 / 2 / 3
Category 4 Total %
Slow, strong pulse / 0 / 1 / 2 / 3 / Palpitations as an adolescent or before menses / 0 / 1 / 2 / 3
Frequent physical activity / 0 / 1 / 2 / 3 / Hypertension, responds to diuretics / 0 / 1 / 2 / 3
Warm bodied / 0 / 1 / 2 / 3 / Injuries/Colds heal quickly / 0 / 1 / 2 / 3
Hands warm, sweaty / 0 / 1 / 2 / 3
Category 5 Total %
Shortness of breath when standing or walking / 0 / 1 / 2 / 3 / Wake up choking or gasping for breath / 0 / 1 / 2 / 3
Tobacco smoker / 0 / 1 / 2 / 3 / Yawns frequently / 0 / 1 / 2 / 3
Difficulty swallowing / 0 / 1 / 2 / 3 / Frequent chest colds / 0 / 1 / 2 / 3
Difficulty coughing up mucus / 0 / 1 / 2 / 3 / Easy coughing up mucus / 0 / 1 / 2 / 3
Rapid, shallow breather / 0 / 1 / 2 / 3 / Sometimes hyperventilates / 0 / 1 / 2 / 3
Category 6 Total %
Dry scalp or hair / 0 / 1 / 2 / 3 / Food causes distress as it passes through / 0 / 1 / 2 / 3
Lips often dry or chapped / 0 / 1 / 2 / 3 / Skin eruptions are deep, not coming to a head / 0 / 1 / 2 / 3
Sores, cracks, fissures in mouth, vagina, or anus / 0 / 1 / 2 / 3 / Cracks fissures- heel, elbow or feet, poorly heal / 0 / 1 / 2 / 3
Category 7 Total % / Sweat freely with strong scent / 0 / 1 / 2 / 3
Oily scalp or hair / 0 / 1 / 2 / 3 / Oily skin, facial acne / 0 / 1 / 2 / 3
Category 8 Total %
Lump in the throat / 0 / 1 / 2 / 3 / Vomiting/Nausea / 0 / 1 / 2 / 3
Difficulty Swallowing / 0 / 1 / 2 / 3 / Strong foot odor / 0 / 1 / 2 / 3
Dry mouth, eyes, and/or nose / 0 / 1 / 2 / 3 / Whites of eyes have a blue tint / 0 / 1 / 2 / 3
Morning stiffness, rigid joints/muscles / 0 / 1 / 2 / 3 / Hoarseness / 0 / 1 / 2 / 3
Chocolate cravings / 0 / 1 / 2 / 3 / Gag easily / 0 / 1 / 2 / 3
Anemia / 0 / 1 / 2 / 3 / White spots on fingernails / 0 / 1 / 2 / 3
Decreased sense of taste or smell / 0 / 1 / 2 / 3 / Bursitis or tendonitis / 0 / 1 / 2 / 3
Cuts heal slowly / 0 / 1 / 2 / 3 / Pain or swelling in joints / 0 / 1 / 2 / 3
Scar easily / 0 / 1 / 2 / 3 / Double jointed or extremely flexible joints / 0 / 1 / 2 / 3
Bone Spurs or history of bone spurs / 0 / 1 / 2 / 3 / Carpal Tunnel Syndrome or history of CTS / 0 / 1 / 2 / 3
Joints pop or click / 0 / 1 / 2 / 3 / History or present lower right abdominal pain / 0 / 1 / 2 / 3
History of stress fractures / 0 / 1 / 2 / 3 / Bone loss (as per bone scan) / 0 / 1 / 2 / 3
History of or present herniated disc / 0 / 1 / 2 / 3 / Calf, foot, or toe cramps at rest / 0 / 1 / 2 / 3
Frequent skin rashes or hives / 0 / 1 / 2 / 3 / Cold sores, fever blisters, or herpes lesions / 0 / 1 / 2 / 3
Frequent fevers / 0 / 1 / 2 / 3 / Canker sores / 0 / 1 / 2 / 3
Category 9 Total %
Polyps or warts / 0 / 1 / 2 / 3 / Vulnerable to insect bites / 0 / 1 / 2 / 3
MSG sensitivity / 0 / 1 / 2 / 3 / Cracks at the corner of mouth / 0 / 1 / 2 / 3
Bleeding gums and/or while brushing teeth / 0 / 1 / 2 / 3 / Loss of muscle tone, heaviness in arms or legs / 0 / 1 / 2 / 3
Strong light at night irritates eyes / 0 / 1 / 2 / 3 / Fragile skin, easily chaffed / 0 / 1 / 2 / 3
Nose bleeds and/or bruise easily / 0 / 1 / 2 / 3 / Enlarged heart or heart failure / 0 / 1 / 2 / 3
Small bumps on back of arms / 0 / 1 / 2 / 3 / Heart races / 0 / 1 / 2 / 3
Take birth control pills / 0 / 1 / 2 / 3 / Ringing in ears / Tinnitus / 0 / 1 / 2 / 3
Can hear heart beat on pillow at night / 0 / 1 / 2 / 3 / Feelings of insecurity / 0 / 1 / 2 / 3
Whole body or limb jerk as falling asleep / 0 / 1 / 2 / 3 / Nervous or agitated / 0 / 1 / 2 / 3
Muscles become easily fatigued / 0 / 1 / 2 / 3 / Depressed / 0 / 1 / 2 / 3
Feel worse or sore after moderate exercise / 0 / 1 / 2 / 3 / Fear impending doom / 0 / 1 / 2 / 3
Night sweats / 0 / 1 / 2 / 3 / Pulse slow / below 65 / 0 / 1 / 2 / 3
Restless leg syndrome / 0 / 1 / 2 / 3 / Numbness, tingling, or itching in extremities / 0 / 1 / 2 / 3
Worrier, apprehensive, anxious / 0 / 1 / 2 / 3 / Wake up without remembering dreams / 0 / 1 / 2 / 3
Category 10 Total %
Dry flaky skin and/or dandruff / 0 / 1 / 2 / 3 / Low or reduced fat diet / 0 / 1 / 2 / 3
Muscles easily fatigued / 0 / 1 / 2 / 3 / Sunburn easily or suffer sun poisoning / 0 / 1 / 2 / 3
Aspirin is an effective pain reliever / 0 / 1 / 2 / 3 / Headaches when out in the hot sun / 0 / 1 / 2 / 3
Tension headaches at base of skull / 0 / 1 / 2 / 3 / Crave fatty or greasy foods / 0 / 1 / 2 / 3
Category 11 Total %
Bad Dreams / 0 / 1 / 2 / 3 / Likes stimulants / 0 / 1 / 2 / 3
Blurred vision / 0 / 1 / 2 / 3 / Lower back pain / 0 / 1 / 2 / 3
Brown spots, bronzing of skin / 0 / 1 / 2 / 3 / Muscle cramps / 0 / 1 / 2 / 3
Bruises easily / 0 / 1 / 2 / 3 / Nails split easily / 0 / 1 / 2 / 3
Can’t gain weight / 0 / 1 / 2 / 3 / Nails weak, ridges / 0 / 1 / 2 / 3
Can’t lose weight / 0 / 1 / 2 / 3 / Toenail fungus, yellow thick, difficult to cut nails / 0 / 1 / 2 / 3
Can’t get started without coffee / 0 / 1 / 2 / 3 / Athletes foot, peeling, or itchy feet / 0 / 1 / 2 / 3
Chemical or spray poisoning / 0 / 1 / 2 / 3 / Nosebleeds frequently / 0 / 1 / 2 / 3
Chronic fatigue, depression / 0 / 1 / 2 / 3 / Pollution heavy in environment / 0 / 1 / 2 / 3
Cry easily without a specific cause / 0 / 1 / 2 / 3 / Ringing in the ears / 0 / 1 / 2 / 3
Depressed for long periods / 0 / 1 / 2 / 3 / Pulse speeds up after meals / 0 / 1 / 2 / 3
Earaches / 0 / 1 / 2 / 3 / Sensitive to cold weather / 0 / 1 / 2 / 3
Eat often or else faint / nervous / 0 / 1 / 2 / 3 / Sensitive to hot weather / 0 / 1 / 2 / 3
Eyes often red or inflamed / 0 / 1 / 2 / 3 / Sensitive to high humidity / 0 / 1 / 2 / 3
Face, eyes get puffy / 0 / 1 / 2 / 3 / Sensitive to low humidity / 0 / 1 / 2 / 3
Facial twitches / 0 / 1 / 2 / 3 / Sexual desire decreased / 0 / 1 / 2 / 3
Gum problems / 0 / 1 / 2 / 3 / Sexual desire increased / 0 / 1 / 2 / 3
Headaches / 0 / 1 / 2 / 3 / Stuffy nose during the day / 0 / 1 / 2 / 3
Headaches in the morning / 0 / 1 / 2 / 3 / Stuffy nose during the night / 0 / 1 / 2 / 3
Heart palpitations after eating / 0 / 1 / 2 / 3 / Tendency to anemia / 0 / 1 / 2 / 3
Highly emotional / 0 / 1 / 2 / 3 / Tremors in hands or neck / 0 / 1 / 2 / 3
Highly controlled / 0 / 1 / 2 / 3 / Varicose veins / 0 / 1 / 2 / 3
Impaired hearing / 0 / 1 / 2 / 3 / Gains weight easily / 0 / 1 / 2 / 3
Increase in weight / 0 / 1 / 2 / 3 / Loses weight easily / 0 / 1 / 2 / 3
Lack of sensation somewhere / 0 / 1 / 2 / 3 / Not always sure of reality, hallucinations / 0 / 1 / 2 / 3
Likes depressants / 0 / 1 / 2 / 3 / Confused easily / 0 / 1 / 2 / 3
Feel free to provide any additional
information regarding symptoms checked above.