Contact Us This field is hidden when viewing the formDateThis form takes 5-10 minutes to complete. For your convenience there is an option to 'Save and Return Later' at the bottom of the form if needed.Name* First Last Email* Enter Email Confirm Email PhoneAge*Rate Your HealthRate each of the following symptoms to the best of your ability based upon your typical health profile over the last year.POINT SCALE:0 = Never had symptom, 1 = Occasionally have it, mild effect, 2 = Occasionally have it, severe effect,3 = Frequently have it, mild effect, 4 = Frequently have it, severe effectSection 1 NotSevere VerySevere Anxiety* 0 1 2 3 4 Mood swings* 0 1 2 3 4 Enraged behavior or anger* 0 1 2 3 4 Excessive shyness, timidity, social phobia (not typical to your personality)* 0 1 2 3 4 Irritability (not typical to your personality)* 0 1 2 3 4 Low body temperature (below 97.3 F)* 0 1 2 3 4 Insomnia (can’t get to sleep or return to sleep)* 0 1 2 3 4 Dizziness* 0 1 2 3 4 Sound in ears (ringing or hearing your heart beat)* 0 1 2 3 4 Psychological symptoms, even thoughts of suicide* 0 1 2 3 4 Sensitivity to sound* 0 1 2 3 4 Section 1 Total:Section 2 NotSevere VerySevere Indecisiveness* 0 1 2 3 4 Feeling of being overwhelmed or fearful* 0 1 2 3 4 Metallic taste in your mouth* 0 1 2 3 4 Bad breath* 0 1 2 3 4 Bleeding gums* 0 1 2 3 4 Sensitive teeth* 0 1 2 3 4 Canker sores or other sores in the mouth* 0 1 2 3 4 Floaters, shadows or swimmers when you read or look into the sky* 0 1 2 3 4 Dyslexia or loss of place while reading, even as a child* 0 1 2 3 4 Swelling eyelids* 0 1 2 3 4 Peeling on the top layer of skin (hands, feet)* 0 1 2 3 4 Dry skin* 0 1 2 3 4 Heart pain (angina) and you are under 45 years old* 0 1 2 3 4 Depression* 0 1 2 3 4 Gout (arthritic pain, especially in big toes)* 0 1 2 3 4 Pain in shoulders or upper back* 0 1 2 3 4 Twitching eyelids* 0 1 2 3 4 Anemia* 0 1 2 3 4 Wrist/ankle drop or weak extensor muscles* 0 1 2 3 4 Hair falls out (not normal male pattern baldness)* 0 1 2 3 4 Section 2 Total:Section 3 NotSevere VerySevere Sensitivity to light* 0 1 2 3 4 Fatigue after exercising (feeling worse)* 0 1 2 3 4 Bad night vision or seeing halos around lights* 0 1 2 3 4 Shortness of breath, with very little effort* 0 1 2 3 4 Excessive thirst and/or frequent urination* 0 1 2 3 4 Red eyes or tearing* 0 1 2 3 4 Blurred vision at times* 0 1 2 3 4 Morning stiffness* 0 1 2 3 4 Sensitivity to smells (chemicals such as petrochemicals, perfumes, air fresheners)* 0 1 2 3 4 Chronic fatigue or weakness* 0 1 2 3 4 Non-restful sleep* 0 1 2 3 4 Section 3 Total:Section 4 NotSevere VerySevere Receive static shock more often & with more dramatic effect than normal* 0 1 2 3 4 Trouble processing new information* 0 1 2 3 4 Word reversal or trouble finding words* 0 1 2 3 4 Sensitivity to touch* 0 1 2 3 4 Short-term memory loss* 0 1 2 3 4 Chronic sinus congestion* 0 1 2 3 4 Dry non-productive cough* 0 1 2 3 4 Muscle twitching* 0 1 2 3 4 Excessive sweating, especially at night* 0 1 2 3 4 Joint pain - not necessarily true arthritis - can move from joint to joint* 0 1 2 3 4 Difficulty losing weight regardless of diet or exercise* 0 1 2 3 4 Persistent fungal or viral infection, including athlete’s foot, warts, jock itch* 0 1 2 3 4 Candida* 0 1 2 3 4 Frequent illness, prolonged illness or sick days* 0 1 2 3 4 Numbness or weakness in arms and legs* 0 1 2 3 4 Headaches* 0 1 2 3 4 Trouble adding or dividing numbers in your head* 0 1 2 3 4 Fluctuating constipation and diarrhea* 0 1 2 3 4 Stomach pain for no apparent reason* 0 1 2 3 4 Appetite swings* 0 1 2 3 4 Frequent muscle aches, cramps, unusual sharp sudden pains* 0 1 2 3 4 Rashes or rosacea* 0 1 2 3 4 Cold extremities (hands and feet)* 0 1 2 3 4 Section 4 Total:Point Scale Total:© 2016 · Revelation Health, LLC. • True Cellular Detox™PhoneThis field is for validation purposes and should be left unchanged. Δ
