Anthony Animal Clinic

Thiamin Questionaire

Restricted to Professional Use


Patient's Name
Date
E-Mail
Phone


INSTRUCTIONS:    Click each box that applies to you.

 1 Depression  23 Cravings for sugar and sweets
 2 Nervousness or anxiety  24 Temper tantrums and/or violent behavior
 3 Sugar intolerance  25 Chronic bed wetting
 4 Lack of appetite or excessive appetite  26 Itchy skin
 5 Vague yet chronic chest pain or shortness of breath  27 Yawing, shortness of breath
 6 Pulse slow, feels irregular  28 Apathy or feelings of impending doom
 7 Chronic indigestion and/or constipation  29 Eye fibrillations (twitches)
 8 Awaken, difficult to return to sleep  30 Frequent urination
 9 Muscle pain after exercising  31 Loss of muscle tissue in the arms or legs
 10 Chronic agitation and irritablility  32 Premenstrual syndrome
 11 Worry, feelings of insecurity  33 Allergies
 12 Chronic fatigue  34 Tendency to asthma
 13 Sleep apnea (breathing disturbance)  35 Tendency to hives
 14 Anger, fear, and/or paranoia  36 Cold hands, ears, feet
 15 Excessively rapid heart beat with only mild or moderate exercise  37 sensitivity to noise
 16 Lack of strength-or heaviness-in arms or legs  38 Mental dullnes and/or poor concentration
 17 Burning and/or numbness of the arms, hands, feet, and/or toes  39 Difficulty falling asleep
 18 Enlarged heart and/or heart failure  40 Night sweats
 19 Low tolerance for pain  41 Restless legs
 20 Swelling of the extremities  42 Daily consumption of two or more alcoholic drinks
 21 Feeling argumentive or quarrelsome  43 Daily consumption of dessert(s)
 22 Low blood pressure  44 Daily consumption of raw fish