Hair Test Questionairre

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3. Gender *This question is required.
6. Dominant hand function
16. Do you have any of the following conditions
16. Do you have any of the following conditionsYesNoUnknown
chronic fatigue
fibromyalgia
brunescence of the crystallline lens
convergence insufficiency (mild)
accomodative insufficiency (mild)
mydriasis (mild)
Have you needed prescription glasses or contacts redone more than once when you got them?
Does your distance vision get blurry on occasion?
Amblyopia
Proptosis
crossing changes in the retina
abnormally fast or slow respiration at rest
dry skin
unusually dry skin
poor balance
tics or twitches of facial muscles
abnormalities on neurological exam
reduced or unusual sensation in hands and feet
desquamation or exfoliative dermaitits or hyperkeratosis on hands or feet or ankles
redness and peeling of the finger pads on occasion
do you sweat less than most people?
Women: have you had amenhorreoa more than once?
are you tired after a shower?
bleeding gums
tender teeth
metallic taste in mouth
blisters or sores in mouth
sore or irritated throat
loss of appetite
headaches
inability to concentrate
dizziness
muscle tremors
chest pains
allergy (describe in more detail on a separate sheet)
bad breath
diverticulosis/itis
diarrhoea and constipation
colic
excessive fatigue
muscles tire easily
sciatic
leg cramps
joint pains
cold hands and feet
tachycardia
anxiety
tension
depression
forgetfulness
shyness
being easily embarrassed
angina
pattern of illness after amalgam placement
unusual development or learning issues through age 8
Any first degree relative believes they have a mercury problem (regardless of your personal opinion about it)
daily volume of urine produced exceeds 2.5 liters on average
19. If you happen to have any clinical laboratory testing available on yourself, or remember results, please fill in the following table. Answer yes if any test was abnormal
19. If you happen to have any clinical laboratory testing available on yourself, or remember results, please fill in the following table. Answer yes if any test was abnormalYesNoUnknown
prolonged QT time, T wave flatteng, ST segment depression or sinus tachycardia on EKG.
any porphyrin above lab limit in blood or urine or stool
elevated venous CO2
low venous CO2
Women: triglycerides <40
Men: triglycerides <50
Cholesterol <130
low HDL cholesterol
cholesterol > 270
Men: low serum iron
Idiopathic elevated AST
Men: ALT more than points above lab limit
Women: ALT higher than 8 units BELOW lab upper normal limit
2xNa + BUN/2.8 + glucose/18 > 290
elevated hematocrit
elevated MCV
elevated MCH
Any low or high thyroid parameter
any lab indicator of low cortisol
low PRL
Low NK cell number, activity, low total T cells, low CD8 cells.
IgE > 292 IU
Any low immune globulin class or subclass
hypoglycemia (even if only your own personal opinion, indicate if so)
elevated pyruvate
elevated lactate
If you have any laboratory measurements of either urine or red blood cell or hair or stool mineral levels, please supply them if that is possible by emailing surveys@livingnetwork.co.za
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