SYMPTOMS: EYES/VISION
336.	Do your eyes itch often?	No / don't know Quite often / moderately Very often / severely
337.	Are your eyes often irritated? This may include a 'sandy-gritty' feeling, the sensation of a foreign object in the eye or permanently moist eyes (excess tears).	No / don't know Occasional mild irritation Frequent mild / some significant irritation Frequent significant / some severe irritation Frequent or constant severe irritation
338.	Are your eyelids sometimes red?	Don't know No Mildly / occasionally Moderately / often Severely / all of the time
339.	Are the whites of your eyes bloodshot (with red/pink veins showing)? Only answer if you have had bloodshot eyes for more than 2 days.	No / for under 2 days / don't know Significant episodes in the past A little - they appear slightly discolored Significantly - numerous individual red veins Seriously - there is a large, very red area
340.	Moistness of eyes. Do your eyes tend to be...?	Usually / very dry Sometimes / slightly dry About average / don't know Sometimes / slightly moist Usually / very moist, to the point of tearing
341.	Are you nearsighted or farsighted? For additional information see optical prescription.	No, my vision is fine / don't know I'm very nearsighted / -7.0 diopters or over I'm somewhat nearsighted / up to -7.0 diopters I'm somewhat farsighted / up to +7.0 diopters I'm very farsighted / +7.0 diopters or over
342.	Focus. Slowly bring a newspaper or book closer to your eyes. Without wearing glasses or contact lenses, approximately how far from your eyes is the page when the regular-size letters start to blur?	I can't do this test / don't know Less than 4 inches (10cm) 4-11 inches (10-28cm) 12-36 inches (30-90cm or 1-3 feet) Over 36 inches (90cm or 3 feet)
343.	How light or dark is the color of your eyes?	Very light (e.g. very light blue or gray) Lighter than average About average / don't know Darker than average Very dark (e.g. very dark brown)
344.	Do the whites of your eyes have more of a yellow (jaundiced) color to them than in previous weeks or months?	Don't know No Probably Definitely
345.	Have you noticed, or have others commented that your eyes seem to be bulging out or protruding?	No / don't know Yes, but not due to hyperthyroidism Yes, due to hyperthyroidism now resolved Yes, but don't know why Yes, due to current hyperthyroidism
346.	Do your eyeballs (not eyelids) jerk or move involuntarily?	Don't know No Rarely Occasionally Yes, frequently noticeably
347.	Vision - poor dark adaptation. Do you have difficulty seeing things when going from a light to a darkened room?	No / don't know Mildly - can see well after very brief adjustment Moderately - I need time to adjust Seriously - can see only a little after a while Severely - can see nothing at all
348.	Eye sensitivity to bright light. Do you feel sunlight is too strong for you, or need to wear sunglasses a lot?	No / don't know Mildly - I occasionally have to shield my eyes Moderately - I often need to shield my eyes Seriously - I always need sunglasses Severely - I can't stand bright sun at all
349.	Have you ever had an eye infection or inflammation?	No / don't know Yes, a minor incident Yes, several minor or one major incident Yes, more than one major incident
350.	Have you ever had a serious eye injury, or eye surgery?	No / don't know Yes, but I have fully recovered Yes, and I still have eye problems
351.	Do you suffer from any other eye conditions or symptoms not mentioned above? For example, Glaucoma, eye pain, eye discharge, vision disturbances, etc.?	No / don't know Yes    More questions later...
352.	Do you have dark circles / areas under your eyes?	No / don't know Yes, some Yes, pronounced
353.	Do you have bags under your eyes?	No / don't know Yes, somewhat Yes, pronounced
354.	Does the outside 1/3 of your eyebrow area have little or no hair growth? In other words, do your eyebrows fail to extend out to edge of your eyes?	No / don't know Yes
Add any additional information here for the questions above: Please mention the question number(s) if possible.
SYMPTOMS: EARS/HEARING
355.	How much wax accumulates in your ears?	Don't know Very little Some, needs very occasional cleaning Quite a lot, requires regular cleaning A lot - blocks ears and requires frequent cleaning
356.	Do you have a diagonal crease (wrinkle) on one or both of your earlobes? A crease may be partial (only partway across the earlobe) or full (completely across the earlobe).	No / don't know Partial crease on one ear Partial crease on both ears Full crease on one ear, possibly partial on other Full crease on both ears
357.	Have you suffered from any ear/hearing problems not mentioned above? For example, Tinnitus, ear infections, recent loss of hearing, earache, etc.?	No / don't know Yes    More questions later...
Add any additional information here for the questions above: Please mention the question number(s) if possible.
SYMPTOMS: NOSE/NASAL
358.	Do you regularly suffer from a runny or drippy nose?	Don't know No Occasionally Yes, moderately Yes, severely
359.	Do you suffer from nasal congestion, mucus that accumulates in the nose, or post-nasal drip?	No / don't know Occasionally / moderately Often / severely
360.	How moist is the inside of your nose when you are not ill and not suffering from an allergic reaction?	Too dry Quite dry Normal / don't know Quite moist Very moist - tends to run
361.	Has your ability to taste or smell decreased from what it used to be?	No / don't know Somewhat Yes, definitely
362.	Do you have sensations of unpleasant smells for no apparent reason?	No / don't know Occasionally / moderate Often / definite
363.	Roughly how often do you get nosebleeds?	Never / rarely / don't know Once or twice per year 3-6 times per year More than 6 times per year
364.	Does your nose / throat mucus, in general, tend to be...?	Clear A mixture / variable / don't know Mostly yellow/green
365.	Sinusitis - have you had sinus headaches or sinus infections?	Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) in the past, no longer a problem Current minor / chronic problem Current major / chronic problem
366.	Has your nose grown abnormally large over the years? Do not include the effects of traumatic injury or a current infection that has caused swelling.	Don't know No Mildly - barely noticeable Moderately Significantly
Add any additional information here for the questions above: Please mention the question number(s) if possible.
SYMPTOMS: ALLERGIES
367.	Do you have a history of allergies as an adult?	Don't know No Minor (1 or 2 mild allergies) Moderate Major (allergies have been a serious issue for me)
368.	Do you have any allergies to particular chemicals?	No / don't know One or two / mild Several / severe
369.	Do you suffer from sulfite sensitivity? Sulfites are often used as food additives and preservatives.	Don't know No, definitely not It is strongly suspected Yes, moderately Yes, extremely
370.	Do you have any allergies or reactions to certain foods which improve if you avoid those foods?	No / don't know One or two mild Several mild / One or two severe Several severe
371.	What amount of refined sugar consumption, if any, produces a noticeable decline in your health?	Don't know Even the smallest amount causes problems Only small amounts are tolerated Moderate amounts are tolerated well I can tolerate regular/large amounts
372.	Do you have Celiac Disease (gluten sensitivity)?	Don't know No, it has been ruled out Probably, but unconfirmed Mild/moderate - confirmed by doctor or lab test Severe - confirmed by doctor or lab test
373.	Do you suffer from hay fever / allergic rhinitis?	Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
374.	Indoor allergies. Do you suffer when exposed to house dust, molds, and so on?	No / don't know Minor episodes now resolved Major episodes now resolved Current minor problem Current major problem
375.	Do you have a tendency towards producing excess mucus or having chronic congestion?	No / don't know Yes, moderate Yes, severe
376.	Have you ever suffered significantly or repeatedly from hives?	One or two minor incidents / don't know No, never A significant problem in the past only Occasionally / moderately Often / severely
377.	How often do you sneeze or have sneezing attacks?	Never / almost never Occasionally / I think I'm average / don't know Moderate sneezing Often / significant sneezing attacks
378.	Do you find that only specific foods cause bloating?	No / don't know Yes
Add any additional information here for the questions above: Please mention the question number(s) if possible.
SYMPTOMS: MIND: GENERAL
379.	Alzheimer's Disease	No / don't know There is good reason to believe I have it Doctors think I might have it I have been diagnosed with it
380.	Senile Dementia (non-Alzheimer's type)	No / don't know There is good reason to believe I have it Doctors think I might have it I have been diagnosed with it
381.	Do you suffer from seizures or convulsions?	No / don't know Minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
382.	Have you ever suffered significant head injury / trauma?	Don't know No, definitely not Moderate - I was knocked unconscious Serious - surgery was required Severe - some brain damage occurred
383.	Do you have Bipolar Disorder? Also called Manic-Depressive Disorder, it consists of mood swings from excitement and elation to depression and despair.	Don't know No, definitely not Probably, mild Yes, moderately Yes, severely
384.	Do you suffer from episodes of confusion or disorientation?	Don't know No Occasionally Often
385.	Are you 'jumpy' or easily startled?	No / average / don't know Quite easily Very easily
386.	How 'clear' is your mind / thinking? A 'clear' mind comes quickly and accurately to conclusions; a 'foggy' mind has trouble doing calculations or making decisions that should normally be simple.	My mind is always/almost always 'foggy' My mind is often 'foggy' Average / don't know My mind is usually 'clear' My mind is always/almost always 'clear'
387.	Decisiveness. How quickly do you make decisions? This is not related to how 'clear' or 'foggy' your mind is: some people with clear minds have great difficulty making a decision, and some people with foggy minds make quick decisions ('snap decisions').	Slowly/with difficulty - I am indecisive With average speed / don't know Quickly/easily - I am very decisive
388.	Do you have difficulty concentrating, keeping your attention focused?	Don't know No Sometimes / slight Often / moderate Always or almost always / severe
389.	Do you suffer from any form of learning disorder?	Don't know No Yes, minor Yes, major
390.	Spontaneity. Are you...?	Very deliberate and cautious Usually deliberate and cautious Average / don't know Usually spontaneous / impulsive Very spontaneous / impulsive
391.	Excitability. Are you...?	Indifferent / hard to stimulate Average / don't know Excitable, easily stimulated
392.	Are you generally overstimulated, with thoughts racing through your mind?	No / don't know Occasionally Often
393.	How active do you keep your mind? For example, do you regularly read or solve problems or puzzles during work or leisure?	Inactive - I prefer casual conversation, TV, etc. Somewhat inactive I'd say I'm about average / don't know More active than average Extremely active - several hours each day
394.	Do you have 'spacey' or unreal feelings?	No / don't know Occasionally Often
395.	Do you suffer from hallucinations?	Don't know No Occasionally Moderately Seriously
396.	Sense of reality. Are you...?	Always very firmly grounded in day-to-day reality Average - realistic, occasional flights of fancy Often detached from reality
397.	Have you been diagnosed with or suspected of having schizophrenia or schizophrenic tendencies?	No / never It has been hinted at only Yes, a significant problem, but in the past only Yes, it is a chronic but minor problem Yes, it is a chronic and serious problem
398.	Do you have a 'type A' personality: intense, hard-driving, often in a hurry?	No / don't know Somewhat Yes, definitely
399.	Motivation. Are you lethargic, full of "get up and go", or somewhere in between?	Lacking in initiative/apathetic/procrastinating Average / don't know Highly motivated - a 'doer' / leader
400.	How serious are you about major factors in your life, such as your education, career, family and future?	I have recently begun taking things very seriously I have always taken things very seriously About average / don't know I have never taken things very seriously I have recently developed a "don't care" attitude
401.	How is your self-esteem / self-image?	Very poor Somewhat poor Average / don't know Good I feel great about myself
402.	Sociability. By nature are you...?	Antisocial/introverted Average / don't know A 'people person'/extroverted
403.	Is your short-term memory failing? Examples of failure include forgetting what you were talking about or why you entered a room, or not being able to remember phone numbers before writing them down.	Don't know No Occasionally / moderately Severely - I forget things often and quickly
404.	Is your long-term memory failing?	No / don't know Somewhat Severely - it is hard to recall past events
405.	How creative (imaginative) are you?	I am not creative Average / don't know I am very creative
406.	How open are you to other people's points of view?	I am stubborn, often unwilling to compromise Average / don't know I am very open to other points of view
407.	Obsessive-Compulsive Disorder / behavior - OCD	Never had it / don't know Probably had it/minor episode(s) now resolved Major episode(s) now resolved Current minor problem Current major problem
408.	Parkinson's Disease	No / don't know There is good reason to believe I have it Doctors think I might have it I have been diagnosed with it
409.	Do you tend to be suspicious of other people, or trusting?	I'm always suspicious of people and their motives Often suspicious I'm average, careful / don't know A bit too trusting of others Much too trusting and frequently 'used'
Add any additional information here for the questions above: Please mention the question number(s) if possible.

GLOSSARY

Allergic Rhinitis (Hay Fever)
Inflammation of the nasal mucous membranes that is caused by specific allergen(s). It is an allergy characterized by sneezing, itchy and watery eyes, a runny or stuffy nose, coughing and a burning/scratchy sensation of the palate and throat.

Allergy (Allergies)
Hypersensitivity caused by exposure to a particular antigen (allergen), resulting in an increased reactivity to that antigen on subsequent exposure, sometimes with harmful immunologic consequences.

Alzheimer's Disease (Alzheimer's)
A progressive disease of the middle-aged and elderly, characterized by loss of function and death of nerve cells in several areas of the brain, leading to loss of mental functions such as memory and learning. Alzheimer's disease is the most common cause of dementia.

Bipolar Disorder (Manic Depression, Manic-Depression, Manic-Depressive)
A disorder is characterized by alternating periods of extreme moods, usually swinging from being overly elated or irritable (mania) to sad and hopeless (depression) and then back again, with periods of normal mood in between. The frequency of the swings between these two states, and the duration of the mood, varies from person to person.

Celiac Disease (Gluten Sensitivity)
A digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten. Common symptoms include diarrhea, increased appetite, bloating, weight loss, irritability and fatigue. Gluten is found in wheat (including spelt, triticale, and kamut), rye, barley and sometimes oats.

Chronic (Chronicity)
Usually referring to chronic illness: Illness extending over a long period of time.

Dementia (Senile Dementia)
An acquired progressive impairment of intellectual function. Marked compromise exists in at least three of the following mental activity spheres: memory, language, personality, visuospatial skills, and cognition (i.e. abstraction and calculation).

Discharge (Discharges)
A secretion, of pus for example, from a wound or bodily orifice.

Farsightedness (Farsighted, Hypermetropia, Hyperopia, Hyperopic)
Trouble seeing objects that are close to your eyes.

Glaucoma
A disease of the eye characterized by vision loss due to an increase in the pressure of fluid within the eye. This rise in pressure results from a build-up of aqueous fluid and leads to progressive damage to the optic nerve that transmits visual signals to the brain. Over time, glaucoma can lead to a gradual loss in peripheral vision. There are usually no signs that you're developing glaucoma until vision loss occurs.

Hallucination (Hallucinations)
A false or distorted perception of objects or events, including sensations of sight, sound, taste, smell or touch, typically accompanied by a powerful belief in their reality.

Learning Disorder (Learning Disabilities, Learning Disability, Learning Disorders)
A generic term that refers to a group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning or mathematical abilities. These disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction. Even though a learning disability may occur along with other handicapping conditions (e.g. sensory impairment, mental retardation, social and emotional disturbance) or environmental influences (e.g. cultural differences, insufficient/inappropriate instruction, psychogenic factors) it is not the direct result of those condition or influences.

Long-Term Memory (Long Term Memory)
The final phase of memory in which information storage may last from hours to a lifetime.

Mucus (Mucous)
The viscous, slippery substance that consists chiefly of mucin, water, cells, and inorganic salts and is secreted as a protective lubricant coating by cells and glands of the mucous membranes.

Nearsightedness (Myopia, Myopic, Nearsighted, Short Sighted)
Trouble seeing at a distance.

Obsessive-Compulsive Disorder (Obsessive Compulsive, Obsessive-Compulsive, OCD)
Those suffering from OCD have obsessions and/or compulsions. Obsessions refer to recurrent and persistent thoughts, impulses, or images that are intrusive and cause severe anxiety or distress. Compulsions refer to repetitive behaviors and rituals (such as hand washing, hoarding, ordering, checking) or mental acts (like counting, repeating words silently, avoiding). These obsessions and compulsions significantly interfere with normal routine, functioning, social activities and relationships.

Optical Prescription
The units used to represent the amount of correction needed in order to normalize vision for distance are called 'diopters'. The more nearsighted or farsighted you are, the higher your prescription is in diopters. Your prescription is usually written as three numbers, for example:

     OD   -4.25 -1.75 X 180
     OS   -5.50 -1.25 X 175
        +2.25 Add OU

OD (referring to the Latin "Ocular Dexter") stands for right eye, and OS ("Ocular Sinister") is for the left eye. The first number (-4.25 and -5.50 in this example) is the degree of spherical nearsightedness or farsightedness. The sign identifies whether you are nearsighted (minus sign) or farsighted (plus sign). The second number (-1.75 and -1.25) is the degree of astigmatism. The number can be written either with a + sign or a - sign. The last and 3rd number (180 and 175) is the axis, or the direction of your astigmatism. An axis of 180 degrees, for example, means the astigmatism is horizontal. Therefore, this prescription means that the patient is moderately nearsighted, with a moderate degree of astigmatism in a horizontal direction. The "add" at the bottom of the prescription is for the reading part of a bifocal glass. It might be unusual for anyone under the age of 40 to need this. Some people only have one number written for each eye. This is when there is no astigmatism.

Parkinson's Disease (Parkinson's)
A chronic, slowly-progressing disease of the nervous system characterized clinically by the combination of tremor, rigidity, extreme slowness of movement, and stooped posture. It is characterized pathologically by loss of dopamine in the substantia nigra.

Post-Nasal Drip
A constant flow of mucous and discharge down the "back of the throat", generally caused by acute infection or allergies. This drip can in turn be responsible for the development of a secondary cough due to irritation of the larynx, and bronchospasm in asthmatic individuals.

Refined Sugar (Refined Sugars)
The term 'refined sugar' includes not only the "sugar" listed in ingredient listings, but also brown sugar, glucose, fructose and dextrose. Obvious sources include jams and jellies; hidden sources are often mayonnaise, ketchup, salad dressings and other condiments.

Schizophrenia
Any of a group of psychotic disorders usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances. Schizophrenia is associated with dopamine imbalances in the brain and defects of the frontal lobe and is caused by genetic, other biological, and psychosocial factors.

Seizure (Seizures)
While there are over 40 types of seizure, most are classed as either partial seizures which occur when the excessive electrical activity in the brain is limited to one area or generalized seizures which occur when the excessive electrical activity in the brain encompasses the entire organ. Although there is a wide range of signs, they mainly include such things as falling to the ground; muscle stiffening; jerking and twitching; loss of consciousness; an empty stare; rapid chewing/blinking/breathing. Usually lasting from between a couple of seconds and several minutes, recovery may be immediate or take up to several days.

Self-Esteem
The extent to which and ways in which people view themselves. People who view themselves favorably have good self-esteems whereas people who view themselves negatively have poor self-esteems. Self-esteem affects a person's behavior dramatically.

Short-Term Memory (Short Term Memory)
Also known as immediate memory or working memory, this is a phase of memory in which a limited amount of information may be held for several seconds to minutes. In general, up to 7 'chunks' of information are stored for about 20 seconds.

Sinuses (Sinus)
Four pairs of air pockets lined with membranes in the bones around the nose. The ethmoid sinuses are located on each side of the nose between the eyes; the maxillary sinuses are located in the cheek above the teeth and below the eyes; the sphenoid sinuses are located deeply behind the eyes; the frontal sinuses are located in the forehead.

Sinusitis
Inflammation of the sinuses, with causes ranging from dust to hay fever. Obstinate cases can be caused by chronic sinus infections or the continued exposure to allergens from food, pets or environmental irritants.

Sulfite Sensitivity
A person can develop sulfite sensitivity (allergy) at any point in their life but the cause is often unknown. Sulfites are sulfur-based compounds that are added by food manufacturers and restaurants for many purposes such as reducing discoloration of light-colored fruits and vegetables; preventing black spots on seafood; inhibiting the growth of microorganisms in fermented foods such as wine; conditioning dough; maintaining the stability and potency of certain medications. The most common symptom is difficulty in breathing. Sulfites give off the gas sulfur dioxide, which can cause irritation in the lungs and cause a severe asthma attack for those who suffer from asthma. Responses vary; sulfites can also cause chest tightness, nausea, hives, or even anaphalactic shock.

Tinnitus (Tinnitis)
A sensation of noise (ringing or roaring) that is caused by a bodily condition and can usually only be heard by the person affected.

Urticaria (Hives)
Commonly known as hives, urticaria is one of the most common dermatological conditions seen by allergists. Urticaria is not just an allergic disease, however. It can be caused by metabolic diseases, medications, infectious diseases, autoimmune disease, or physical sensitivity. Traditional allergies to foods or medications as well as viral illness are frequent causes of acute urticaria which usually lasts only a few hours but may last up to 6 weeks. Chronic urticaria (lasting more than 6 weeks) is more complex, given the vast number of potential triggers. Symptoms include sudden onset; initial itching; then swelling of the surface of the skin into red or skin-colored welts (wheals) with clearly defined edges; welts turn white on touching; new welts develop when the skin is scratched; usually disappear within minutes or hours. Welts enlarge, change shape, spread or join together to form large flat raised areas.