Symptom Survey Form This form must be submitted before your appointment

Symptom Survey FormThis form must be submitted before your appointment

First Name

Last Name

INSTRUCTIONS: Fill in only the circles which apply to you. Leave circles BLANK if they do not apply to you!MILD symptoms (occurred once or twice last 6 months)MODERATE symptoms (occurred once or twice last months)SEVERE symptoms (occurred once or twice last week)Leave circles BLANK if they don"t apply to you!

GROUP 1 (sym)

Rows	MILD	MODERATE	SEVERE
1 Acid foods upset
2 Get chilled often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meal
6 Keyed up - fail to calm
7 Cut heals slowly
8 Gag easily
9 Unable to relax; startles easily
10 Extremities cold, clammy
11 Strong light irritates
12 Urine amount reduced
13 Heart pounds after retiring
14 "Nervous" stomach
15 Appetite reduced
16 Cold sweats often
17 Fever easily raised
18 Neuralgia-like pains
19 Staring, blinks little
20 Sour stomach often

GROUP 2 (para)

Rows	MILD	MODERATE	SEVERE
21 Joint stiffness on arising
22 Muscle-leg-toe cramps at night
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen, puffy
27 Indigestion soon after meals
28 Always seems hungry; feels "light-headed" often
29 Digestion rapid
30 Vomiting frequent
31 Hoarseness frequent
32 Breathing irregular
33 Pulse slow; feels "irregular"
34 Gagging reflex slow
35 Difficulty swallowing
36 Constipation, diarrhea alternating
37 "Slow starter"
38 Get "chilled" infrequently
39 Perspire easily
40 Circulation poor, sensitive to cold
41 Subject to colds, asthma, bronchitis

GROUP 3 (glu)

Rows	MILD	MODERATE	SEVERE
42 Eat when nervous
43 Excessive appetite
44 Hungry between meals
45 Irritable before meals
46 Get "shaky" if hungry
47 Fatigue, eating relieves
48 "Light-headed" if meals delayed
49 Heart palpitates if meals missed or delayed
50 Afternoon headaches
51 Overeating sweets upsets
52 Awaken after few hours sleep - hard to get back to sleep
53 Crave candy or coffee in afternoons
54 Moods of depression - "blues" or melancholy
55 Abnormal craving for sweets or snacks

Group 4 (cv)

Rows	MILD	MODERATE	SEVERE
56 Hand and feet go to sleep easily, numbness
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 High altitude discomfort
60 Opens windows in closed rooms
61 Susceptible to colds and fevers
62 Afternoon "yawner"
63 Get "drowsy" often
64 Swollen ankles, worse at night
65 Muscle cramps, worse during exercise; get "charley horses"
66 Shortness of breath on exertion
67 Dull pain in chest or radiating into left arm, worse on exertion
68 Bruise easily, "black and blue" spots
69 Tendency to anemia
70 "Nose bleeds" frequent
71 Noises in head, or "ringing in ears"
72 Tension under the breastbone, or feeling of "tightness", worse on exertion

Group 5 (L,gb)

Rows	MILD	MODERATE	SEVERE
73 Dizziness
74 Dry Skin
75 Burning feet
76 Blurred vision
77 Itching skin and feet
78 Excessive falling hair
79 Frequent skin rashes
80 Bitter, metallic taste in mouth in mornings
81 Bowel movements painful or difficult
82 Worrier, feels insecure
83 Feeling queasy; headache over eyes
84 Greasy food upset
85 Stools light colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Use laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks or gallstones
91 Sneezing attacks
92 Dreaming, nightmare type bad dreams
93 Bad breath (halitosis)
94 Milk products cause distress
95 Sensitive to hot weather
96 Burning or itching anus
97 Crave sweets

GROUP 6 (gi)

Rows	MILD	MODERATE	SEVERE
98 Loss of taste for meat
99 Lower bowel gas several hours after eating
100 Burning stomach sensations, eating relieves
101 Coated tongue
102 Pass large amounts of foul-smelling gas
103 Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs.
104 Mucous colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating

GROUP 7A (hyp-t)

Rows	MILD	MODERATE	SEVERE
107 Insomnia
108 Nervousness
109 Can"t Gain Weight
110 Intolerance to heat
111 Highly Emotional
112 Flush easily
113 Night sweats
114 Thin, moist skin
115 Inward trembling
116 heart palpitates
117 Increased appetite without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can"t work under pressure

GROUP 7B (hyo-t)

Rows	MILD	MODERATE	SEVERE
122 Increase in weight
123 Decrease in appetite
124 Fatigue easily
125 Ringing in ears
126 Sleepy during day
127 Sensitive to cold
128 Dry or scaly skin
129 Constipation
130 Mental sluggishness
131 Hair coarse, falls out
132 Headaches upon rising, wear off during day
133 Slow pulse, below 65
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative

GROUP 7C (hyp-pit)

Rows	MILD	MODERATE	SEVERE
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches, "splitting or rendering" type
141 Decreased sugar tolerance

GROUP 7D (hyo-pit0

Rows	MILD	MODERATE	SEVERE
142 Abnormal thirst
143 Bloating of abdomen
144 Weight gain around hips or waist
145 Sex drive reduced or lacking
146 Tendency to ulcers, colitis
147 Increased sugar tolerance
148 Women; menstrual disorders
149 Young girls: lack of menstrual function

GROUP 7E (hyp-ad)

Rows	MILD	MODERATE	SEVERE
150 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 Hair growth on face or body (female)
155 Sugar in urine (not diabetes)
156 Masculine tendencies (female)

GROUP 7F hyo-ad

Rows	MILD	MODERATE	SEVERE
157 Weakness, dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails weak, ridged
161 Tendency to hives
162 Arthritic tendencies
163 Perspiration increase
164 Bowel disorders
165 Poor circulation
166Swollen ankles
167 Crave salt
168 Brown spots or bronzing of skin
169 Allergies - tendency to asthma
170 Weakness after colds, influenza
171 Exhaustion - muscular and nervous
172 Respiratory disorders

GROUP 8 (b-comp)

Rows	MILD	MODERATE	SEVERE
173 Apprehension
174 Irritability
175 Morbid fears
176 Never seems to get well
177 Forgetfulness
178 Indigestion
179 Poor appetite
180 Craving for sweets
181 Muscular soreness
182 Depression; feelings of dread
183 Noise sensitivity
184 Acoustic hallucinations
185 Tendency to cry without reason
186 Hair is coarse and/or thinning
187 Weakness
188 Fatigue
189 Skin sensitive to touch
190 Tendency toward hives
191 Nervousness
192 Headache
193 Insomnia
194 Anxiety
195 Anorexia
196 Inability to concentrate; confusion
197 Frequent stuffy nose; sinus infections
198 Allergy to some foods
199 Loose joints

FEMALE ONLY

Rows	MILD	MODERATE	SEVERE
200 Very easily fatigued
201 Premenstrual tension
202 Painful menses
203 Depressed feelings before menstruation
204 Menstruation excessive and prolonged
205 Painful breasts
206 Menstruate too frequently
207 Vaginal discharge
208 Hysterectomy / ovaries removed
209 Menopausal hot flashes
210 Menses scanty or missed
211 Acne, worse at menses
212 Depression of long standing

MALE ONLY

Rows	MILD	MODERATE	SEVERE
213 Prostate trouble
214 Urination difficult or dribbling
215 Night urination frequent
216 Depression
217 Pain on inside of legs or heels
218 Feeling of incomplete bowel evacuation
219 Lack of energy
220 Migrating aches and joints
221 Tire too easily
222 Avoids activity
223 Leg nervousness at night
224 Diminished sex drive

List the five main complaints you have in the order of their importance

Email (required if you would like confirmation of your submission)