Name: Dr. Lisa Ballehr - Functional Medicine
Address: Mesa, Arizona, 85207, United States
Telephone: +1 (480) 395-9220
Price range: $$$$

Head
Headaches*
- 0
- 1
- 2
- 3
- 4
Faintness*
- 0
- 1
- 2
- 3
- 4
Dizziness*
- 0
- 1
- 2
- 3
- 4
Insomnia*
- 0
- 1
- 2
- 3
- 4
Total

EYES
Watery or itchy eyes*
- 0
- 1
- 2
- 3
- 4
Swollen, reddened or sticky eyelids*
- 0
- 1
- 2
- 3
- 4
Bags or dark circles under eyes*
- 0
- 1
- 2
- 3
- 4
Blurred or tunnel vision (does not include near or far-sightedness)*
- 0
- 1
- 2
- 3
- 4
Total

EARS
Itchy ears*
- 0
- 1
- 2
- 3
- 4
Earaches, ear infections*
- 0
- 1
- 2
- 3
- 4
Drainage from ear*
- 0
- 1
- 2
- 3
- 4
Ringing in ears, hearing loss*
- 0
- 1
- 2
- 3
- 4
Total

NOSE
Stuffy nose*
- 0
- 1
- 2
- 3
- 4
Sinus problems*
- 0
- 1
- 2
- 3
- 4
Hay fever*
- 0
- 1
- 2
- 3
- 4
Sneezing attacks*
- 0
- 1
- 2
- 3
- 4
Excessive mucus formation*
- 0
- 1
- 2
- 3
- 4
Total

MOUTH/THROAT
Chronic coughing*
- 0
- 1
- 2
- 3
- 4
Gagging, frequent need to clear throat*
- 0
- 1
- 2
- 3
- 4
Sore throat, hoarseness, loss of voice*
- 0
- 1
- 2
- 3
- 4
Swollen/discolored tongue, gum, lips*
- 0
- 1
- 2
- 3
- 4
Canker sores*
- 0
- 1
- 2
- 3
- 4
Total

SKIN
Acne*
- 0
- 1
- 2
- 3
- 4
Hives, rashes or dry skin*
- 0
- 1
- 2
- 3
- 4
Hair loss*
- 0
- 1
- 2
- 3
- 4
Flushing or hot flushes*
- 0
- 1
- 2
- 3
- 4
Excessive sweating*
- 0
- 1
- 2
- 3
- 4
Total

HEART
Irregular or skipped heartbeat*
- 0
- 1
- 2
- 3
- 4
Rapid or pounding heartbeat*
- 0
- 1
- 2
- 3
- 4
Chest pain*
- 0
- 1
- 2
- 3
- 4
Total

DIGESTIVE TRACT
Nausea or vomiting*
- 0
- 1
- 2
- 3
- 4
Diarrhea*
- 0
- 1
- 2
- 3
- 4
Constipation*
- 0
- 1
- 2
- 3
- 4
Bloated feeling*
- 0
- 1
- 2
- 3
- 4
Belching or passing gas*
- 0
- 1
- 2
- 3
- 4
Heartburn*
- 0
- 1
- 2
- 3
- 4
Intestinal/Stomach pain*
- 0
- 1
- 2
- 3
- 4
Total

LUNGS
Chest congestion*
- 0
- 1
- 2
- 3
- 4
Asthma, bronchitis*
- 0
- 1
- 2
- 3
- 4
Shortness of breath*
- 0
- 1
- 2
- 3
- 4
Difficult breathing*
- 0
- 1
- 2
- 3
- 4
Total

JOINTS/MUSCLES
Pain or aches in joints*
- 0
- 1
- 2
- 3
- 4
Arthritis*
- 0
- 1
- 2
- 3
- 4
Stiffness or limitation of movement*
- 0
- 1
- 2
- 3
- 4
Pain or aches in muscles*
- 0
- 1
- 2
- 3
- 4
Feeling of weakness or tiredness*
- 0
- 1
- 2
- 3
- 4
Total

WEIGHT
Binge eating/drinking*
- 0
- 1
- 2
- 3
- 4
Craving certain foods*
- 0
- 1
- 2
- 3
- 4
Excessive weight*
- 0
- 1
- 2
- 3
- 4
Compulsive eating*
- 0
- 1
- 2
- 3
- 4
Water retention*
- 0
- 1
- 2
- 3
- 4
Underweight*
- 0
- 1
- 2
- 3
- 4
Total

ENERGY/ACTIVITY
Fatigue, sluggishness*
- 0
- 1
- 2
- 3
- 4
Apathy, lethargy*
- 0
- 1
- 2
- 3
- 4
Hyperactivity*
- 0
- 1
- 2
- 3
- 4
Restlessness*
- 0
- 1
- 2
- 3
- 4
Total

MIND
Poor memory*
- 0
- 1
- 2
- 3
- 4
Confusion, poor comprehension*
- 0
- 1
- 2
- 3
- 4
Poor concentration*
- 0
- 1
- 2
- 3
- 4
Poor physical coordination*
- 0
- 1
- 2
- 3
- 4
Difficulty in making decisions*
- 0
- 1
- 2
- 3
- 4
Stuttering or stammering*
- 0
- 1
- 2
- 3
- 4
Slurred speech*
- 0
- 1
- 2
- 3
- 4
Learning disabilities*
- 0
- 1
- 2
- 3
- 4
Depression*
- 0
- 1
- 2
- 3
- 4
Total

EMOTIONS
Mood swings*
- 0
- 1
- 2
- 3
- 4
Anxiety, fear, or nervousness*
- 0
- 1
- 2
- 3
- 4
Anger, irritability, or aggressiveness*
- 0
- 1
- 2
- 3
- 4
Total

OTHER
Frequent illness*
- 0
- 1
- 2
- 3
- 4
Frequent or urgent urination*
- 0
- 1
- 2
- 3
- 4
Genital itch or discharge*
- 0
- 1
- 2
- 3
- 4
Total

Welcome

Head

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

DIGESTIVE TRACT

LUNGS

JOINTS/MUSCLES

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

KEY TO QUESTIONNAIRE

Checkout Our New Courses

Important Details