Comprehensive symptom quiz

1

Hi there! What's your first name?* This field is required.

2

How old are you? * This field is required.

3

What's your gender?* This field is required.

Female

Male

4

Are you here for help with fertility?

YESNO

5

What brings you here today?* This field is required.

I'm looking for help with fertility

I am looking for help with my symptoms

I might have COVID

6

What symptoms are you experiencing?* This field is required.Check all that apply

Cough

Fever

Shortness of breath

None of these

8

We are now offering an Immune Support Program to help you stay healthy.

To learn more about the program please click here. If this is not what you were looking for, please hit "PREVIOUS" below and make a different selection.

9

We are sorry. but we are not currently equipped to assist with COVID-19.

We recommend you go through a formal screening process for testing by one of your local hospitals, clinics, or health systems.

You may exit this quiz now or go back and make a different selection.

10

Please tell us how often or how severely you experience the following symptoms

11

Not sleeping well (trouble falling or staying asleep)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

12

Moody or irritable

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

13

Decreased libido and sex drive

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

14

Anxious

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

15

Foggy brain, thinking, or memory

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

16

Dry eyes, hair, or dry skin

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

17

Fatigued, sluggish, or constantly tired

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

18

Thinning head hair

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

19

Palpitations (skipped heart beats or heart pounding)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

20

Hot flashes or night sweats

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

21

Vaginal dryness and painful sex

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

22

Excess body hair on face, chest, or arms

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

23

Irregular menstrual cycles, heavy or painful periods

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

24

Sexual performance is not as good as it used to be

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

25

Decrease in strength and endurance

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

26

Feeling less social

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

27

Must have caffeine or sugar to get or keep going

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

28

Catch more colds or takes longer to recover from illness

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

29

Feeling overwhelmed

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

30

Feeling tired and anxious (“tired and wired”)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

31

Losing hair on eye brows or eyelashes

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

32

Thin and brittle fingernails

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

33

Cold hands and feet or feeling colder than everyone else

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

34

Constipation

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

35

Change in bowel movements (constipation or diarrhea)

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

36

Abdominal bloating, uncomfortable gas, indigestion, or heartburn

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

37

Certain foods cause abdominal discomfort or diarrhea

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

38

Have eczema or chronic skin rashes or itching

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

39

Have a diagnosed autoimmune condition

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

40

Unexplained weight gain, or difficulty losing weight

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

41

Have you tried to become pregnant in the last 6 months unsuccessfully?

YESNO

42

Do you have a history of at least one miscarriage?

YESNO

43

Are you currently under the care of a fertility specialist (reproductive endocrinologist) and would like to enhance your chances of getting pregnant?

YESNO

44

Are you hoping to conceive naturally, without medications or procedures?

YESNO

45

Do you have a difficult time going to or staying asleep?

YESNO

46

Are you under a lot of stress?

YESNO

47

Have you noticed your hair thinning?

YESNO

48

Do you have irregular periods?

YESNO

49

Do you have very heavy periods?

YESNO

50

Do you have bothersome stomach symptoms like indigestion, heartburn, bloating, diarrhea, or constipation?

YESNO

51

How frequently do you feel exhausted?

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

52

Have you gained weight around your belly?

Not a problem or never true

Minor or seldom true

Mild or sometimes true

Moderate or often true

Severe or very frequent

53

If you found a doctor who can help you with your symptoms, how soon would you want to see them?

As soon as possible

This week

This month

Not sure

54

How many clinicians (doctors, specialists, alternative medicine practitioners, etc.) have you seen for these symptoms?

1-2 different clinicians

3-5 different clinicians

6-9 different clinicians

over 10 different clinicians

55

How familiar are you with holistic and functional medicine?

Not at all

I know a little bit

I've done my research & know enough

I've been using it for a while

I'm an expert

56

What's your email* This field is required.We need your email so we can send you the results and other useful information

example@example.com

57

What state do you live in?* This field is required.Your state will help us show you available clinicians in your area

58

Would you like someone on our team to call you and help figure out if we are the right solution for you?* This field is required.We are not telemarketers and will only call about this topic.

YESNO

59

What's your phone number

Area Code

Phone Number

60

Your Hormone Balance Score (anything over 37 may indicate Hormonal Imbalance)

61

Your Adrenal Health Score (anything over 20 may indicate Adrenal Fatigue)

62

Your Thyroid Function Score (anything over 28 may indicate a Thyroid Disorder)

63

Your Gut Function Score (anything over 24 may indicate a gut imbalance)

64

By clicking submit, you agree for Vytal Health to store and process your information to provide you with the content requested.* This field is required.You are subscribing to updates regarding this request plus other health opportunities. You may unsubscribe from these communications at any time, check out our Privacy Policy.

65

Please verify that you are human* This field is required.

66

We are now offering an Immune Support Program to help you stay healthy.

We are sorry. but we are not currently equipped to assist with COVID-19.

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