test of wpforms for intake form - Growing Holistically

Name *

First

Last

Email *

Acid foods upset (0 = never, 5 = often)

Selected Value: 0

Get chilled often (0 = never, 5 = often)

Selected Value: 0

"Lump" in throat (0 = never, 5 = often)

Selected Value: 0

Dry mouth, eyes, nose (0 = never, 5 = often)

Selected Value: 0

Pulse speeds after meal (0 = never, 5 = often)

Selected Value: 0

Keyed up, fail to calm (0 = never, 5 = often)

Selected Value: 0

Gag occasionally (0 = never, 5 = often)

Selected Value: 0

Unable to relax, startle easily (0 = never, 5 = often)

Selected Value: 0

Extremities cold, clammy (0 = never, 5 = often)

Selected Value: 0

Strong light irritates (0 = never, 5 = often)

Selected Value: 0

Occasionally weak urine flow (0 = never, 5 = often)

Selected Value: 0

Heart pounds after retiring (0 = never, 5 = often)

Selected Value: 0

5 often)

"Nervous" stomach (0 = never, 5 = often)

Selected Value: 0

Appetite reduced occasionally (0 = never, 5 = often)

Selected Value: 0

Cold sweats often (0 = never, 5 = often)

Selected Value: 0

Get heated easily (0 = never, 5 = often)

Selected Value: 0

Nerve discomfort (0 = never, 5 = often)

Selected Value: 0

Staring, blink little (0 = never, 5 = often)

Selected Value: 0

Sour stomach frequent (0 = never, 5 = often)

Selected Value: 0

Any other concerns? *