Symptoms |
Comments |
General |
Extreme tiredness |
0 |
1 |
2 |
3 |
.............................. |
Weight gain? How much? |
.............................. |
Weight loss? How much? |
.............................. |
Lack of energy |
0 |
1 |
2 |
3 |
.............................. |
Aching muscles |
0 |
1 |
2 |
3 |
.............................. |
Where? |
.............................. |
Backache? |
.............................. |
Heart palpitations |
0 |
1 |
2 |
3 |
.............................. |
Headache |
0 |
1 |
2 |
3 |
.............................. |
Infections |
0 |
1 |
2 |
3 |
.............................. |
Where? |
.............................. |
Thyroid gland, goitre? |
.............................. |
Mouth |
Metal taste |
0 |
1 |
2 |
3 |
.............................. |
Other |
.............................. |
Stomach-Intestines |
Diarrhoea |
0 |
1 |
2 |
3 |
.............................. |
Bruises |
0 |
1 |
2 |
3 |
.............................. |
Swollen stomach |
0 |
1 |
2 |
3 |
.............................. |
Menstruation Problems |
0 |
1 |
2 |
3 |
.............................. |
Sight |
Clouded vision |
0 |
1 |
2 |
3 |
.............................. |
Impaired vision in the dark |
0 |
1 |
2 |
3 |
.............................. |
Other |
.............................. |
Hypersensitive to |
Light |
0 |
1 |
2 |
3 |
.............................. |
Sound |
0 |
1 |
2 |
3 |
.............................. |
Smells |
0 |
1 |
2 |
3 |
|
Pain |
0 |
1 |
2 |
3 |
.............................. |
Electricity |
0 |
1 |
2 |
3 |
.............................. |
Other |
.............................. |
Reduced Capability |
Impaired sense of smell |
0 |
1 |
2 |
3 |
.............................. |
Numbness |
0 |
1 |
2 |
3 |
.............................. |
Paralysis |
0 |
1 |
2 |
3 |
.............................. |
Giddiness |
0 |
1 |
2 |
3 |
.............................. |
Clumsiness |
0 |
1 |
2 |
3 |
.............................. |
Concentration difficulties |
0 |
1 |
2 |
3 |
.............................. |
Easily get angry |
0 |
1 |
2 |
3 |
.............................. |
Forgetfulness (recent occurrences) |
0 |
1 |
2 |
3 |
.............................. |
Depression |
0 |
1 |
2 |
3 |
.............................. |
Lack of Reaction |
0 |
1 |
2 |
3 |
|
Unmotivated crying |
0 |
1 |
2 |
3 |
.............................. |
Feeling "frozen" |
0 |
1 |
2 |
3 |
.............................. |
Fever |
0 |
1 |
2 |
3 |
.............................. |
Sinus infection |
0 |
1 |
2 |
3 |
.............................. |
Constipation |
0 |
1 |
2 |
3 |
.............................. |
Allergy |
0 |
1 |
2 |
3 |
.............................. |
Hair condition? eg lack of lustre, loss |
.............................. |
How long have you been ill? |
.............................. |
How many of your teeth have amalgam fillings? |
.............................. |
How many gold or metal crowns do you have? |
.............................. |
If you have no amalgam left in your mouth, in what year was it removed? |
.............................. |
Did your health improve or deteriorate afterwards? |
.............................. |
Do you smoke or use snuff? |
yes ........ no ......... |
Do you eat "plain food"? |
.............................. |
Vegetarian food? |
.............................. |
Other diet? |
.............................. |
Do you use the coil as a contraceptive? |
.............................. |
What medicine do you take? |
.............................. |
Have you been examined by a doctor? |
yes ........ no ......... |
