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Client Information: Continued Page (8) 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 TEN

1. Frequent urination
5. Cloudy urine
8. Painful/burning when passing urine
2. Rose colored (bloody) urine
6. Rarely need to urinate
9. Urination when you cough or sneeze
3. Dripping after urination
7. Frequent bladder infections
10. Strong smelling urine
4. Difficulty passing urine

GROUP ELEVEN

Section A
1. Throat infections
4. Gets boils or styes
7. Bumpy skin on back
of arms
2. Poor wound healing
5. Swollen lymph glands
8. Inflamed or bleeding
gums
3. Slow to recover from cold or flu
6. Catch colds or flu too easily
Section B
9. Chronic lung congestion
11. Breathe through mouth
13. Hyperactivity
10. Post nasal drip
12. Swollen tongue
14. Food sensitivity or
allergy