Section A: History
Have you taken tetracycline's (or other antibiotics) for 2 months (or longer)?
Have you, at any time in your life, taken other antibiotics (Including Keflex®, ampicillin, amoxicillin, Ceclor®, Bactrim®, Erythromycin, and Septra®*) for 2 months or longer, or in shorter courses 3 or more times in a 1-year period?
Have you taken Prednisone, Decadron® or other cortisone-type drugs?
Does exposure to perfumes, tobacco smoke, insecticides, soaps, fabric drying sheets, odors and other chemicals provoke...
Section A: History
Are your symptoms worse on damp, muggy days or in moldy places?
Have you had athlete's foot, "jock itch", or other infections of the skin or nails? Have such infections been ...
Do you crave sugar or breads?
Do you crave alcoholic beverages?
Section B: Major Symptoms
Fatigue, Feeling "drained" or Lethargy.
Poor memory or feeling "spacey"
Depression
Section B: Major Symptoms
Numbness, burning or tingling
Muscle aches or muscle weakness
Loss of sexual feeling
Pain and/or swelling in joints or arthritis
Section B: Major Symptoms
Abdominal pain
Constipation or Diarrhea
Bloating
Spots in front of eyes or erratic or failing vision
Section C: Other Symptoms
Drowsiness
Irritability, jitters or incoordination
Inability to concentrate
Frequent mood swings
Section C: Other Symptoms
Headache(s)
Dizziness / loss of balance
Pressure above ears...feeling of head swelling or tingling
Iching Skin or Rashes
Section C: Other Symptoms
Heartburn or Indigestion
Belching and intestinal gas
Hemorrhoids or mucus in stools?
Rash or blisters in mouth
Section C: Other Symptoms
Bad breath
Nasal congestion or discharge
Postnasal drip
Nasal itching
Section C: Other Symptoms
Dry mouth or sore or dry throat
Cough
Pain or tightness in chest
Wheezing or shortness of breath
Urgency or urinary frequency and/or burning urination?
Section C: Other Symptoms
Burning or tearing eyes
Ear pain, ear infections or fluid in ears
Tubes in ears
Section D: Men
Inflammation of the Prostate
Impotence
Section E: Women
Have you, at any time in your life, been troubled by persistent vaginal problems or had 3 or more episodes of vaginitis in a year?
Have you been pregnant?
Have you taken birth control pills?
Painful Menstruation, Cramps
Endometriosis
Persistent vaginal burning or itching or troublesome vaginal discharge
Premenstrual tension
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