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Client Information: Continued Page (7) of 9

Name Date

INSTRUCTIONS
Number the weaknesses which apply to you.  If it doesn't apply, leave it blank.

Use: (1) - for Mild symptoms / (2) • for Moderate symptoms / (3) - for Severe Symptoms.

GROUP EIGHT
(Female Only)

1. Painful menses
5. Menstruation excessive and prolonged
9. Menopause hot flashes, etc.
2. Premenstrual tension
6. Painful breasts
10. Menses scanty
3. Very easily fatigued.
7. Menstruate too frequently
11. Arne, worse at menses
4. Depressed feeling
before menstruation
8. Vaginal discharge

(Male Only)

12. Tire too easily
15. Pain on inside of legs or heel
18. Leg nervousness at night
13. Urination difficult
16. Feeling of incomplete bowel evacuation
19. Diminished sex desire
14. Night urination frequent
17. Prostate trouble

GROUP NINE

1. Chronic cough
5. Difficulty breathing
8. Bronchitis (frequent)
2. Pain around ribs
6. Coughing up phlegm
9. Infections settle in lungs
3. Shortness of breath
7. Coughing up blood
10. Sensitive to smog
4. Chest pain