Symptom Survey Online Form

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Birthday:    Month    Day    Year  
SEX:   Male        Female
HEIGHT:       WEIGHT: 

INSTRUCTIONS: Check one of the 4 circles: 1-does not apply , 2-mild, 3-moderate, 4-severe

This Symptom Survey has 212 questions,  Please be aware that it will take a few minutes to fill this survey out in it's entirety.  You will not be charged for filling out this form today, however there is a $20 processing fee which will be due before you will receive the results from this Survey.

  NA 1 2 3  
    Does Not Apply ( selected as shown if the symptom does not apply to you)
    MILD symptoms (once or twice last 6 month)
    MODERATE symptoms (once or twice last month)
    SEVERE symptoms (Chronic, once or twice last wk)
           
  NA 1 2 3   GROUP 1 SYMPATHETIC DOMINANCE
1

Acid foods upset
2 Feel chilled often
3 "Lump" in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meals
6 Keyed up; unable to feel calm
7 Cuts heal slowly
8 Gag easily
9 Unable to relax; startles easily
10 Extremities cold and/or 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 Body temperature rises easily
18 Skin sensitive to touch
19 Staring, blinks little
20 Frequently have a sour stomach
           
  NA 1 2 3   GROUP 2  PARASYMPATHETIC DOMINANCE
21 Joint stiffness after arising
22 Muscle-leg-toe cramps at night
23 "Butterfly" stomach, cramps
24 Eyes or nose watery
25 Eyes blink often
26 Eyelids swollen or puffy
27 Indigestion soon after meals
28 Always seem hungry; 'lightheaded' often
29 Food digests rapidly
30 Vomit frequently
31 Frequently hoarse
32 Irregular breathing
33 Pulse slow or feels "irregular"
34 Slow gag reflex
35 Difficulty swallowing
36 Alternating constipation and diarrhea
37 "Slow starter"
38 Not easily chilled
39 Perspire easily
40 Poor circulation or sensitive to cold
41 Subject to colds, asthma, bronchitis
           
  NA 1 2 3 GROUP 3 SUGAR HANDLING
42 Eat when nervous
43 Excessive appetite
44 Hungry between meals
45 Irritable before meals
46 Get "shaky" if hungry
47 Feeling fatigued, eating relieves
48 "Lightheaded" if meals delayed
49 Heart palpitates if meals missed or delayed
50 Afternoon headaches
51 Upset feeling from excessive eating of sweets
52 Awaken after a 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
           
  NA 1 2 3 GROUP 4 CARDIOVASCULAR
56 Hands and feet go to sleep easily, numbness
57 Sigh frequently, "air hunger"
58 Aware of "breathing heavily"
59 Discomfort at high altitude
60 Opens windows in closed room
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; "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/blue" spots on arms or legs
69 Tendency to anemia
70  Frequently have "nose bleeds"
71 "Ringing in ears" or noises in head
72 Tension under the breast-bone, or feeling of "tight­ness" in the chest, gets worse on exertion
           
  NA 1 2 3 GROUP 5 LIVER/BILIARY
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 or metallic taste in mouth in the mornings
81 Bowel movements painful or difficult
82 Feelings of worry, dread, or insecurity
83 Feeling queasy; headache over eyes
84 Greasy foods upset
85 Stools light-colored
86 Skin peels on foot soles
87 Pain between shoulder blades
88 Using laxatives
89 Stools alternate from soft to watery
90 History of gallbladder attacks or gall stones
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
           
  NA 1 2 3 GROUP 6 DIGESTION
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 Mucus colitis or "irritable bowel"
105 Gas shortly after eating
106 Stomach "bloating" after eating
           
  NA 1 2 3  
    Does Not Apply ( leave it blank or selected as shown if the symptom does not apply to you)
    MILD symptoms (once or twice last 6 month)
    MODERATE symptoms (once or twice last month)
    SEVERE symptoms (Chronic, once or twice last wk)
           
  NA 1 2 3 GROUP 7A HYPERTHYROID
107 Insomnia
108 Nervousness
109 Can't gain weight
110 Intolerance to heat
111 Highly emotional
112 Flush easily
113 Night sweats
114 Skin is thin and moist
115 Inward trembling
116 Heart palpitates
117 Increased appetite without weight gain
118 Pulse races when resting
119 Eyelids and face twitch
120 Irritable and restless
121 Can't work under pressure
           
  NA 1 2 3 GROUP 7B HYPOTHYROID
122 Noticeable weight gain
123 Decrease in appetite
124 Easily fatigued
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 arising wear off during day
133 Slow pulse, below 65
134 Frequent urination
135 Impaired hearing
136 Reduced initiative
           
  NA 1 2 3 GROUP 7C HYPERPITUITARY
137 Failing memory
138 Low blood pressure
139 Increased sex drive
140 Headaches, "splitting or rendering" type
141  Decreased sugar tolerance
           
  NA 1 2 3 GROUP 7D HYPOPITUITARY
142 Abnormal thirst
143 Bloating of the abdomen
144 Weight gain around hips or waist
145 Sex drive reduced or lacking
146 Tendency toward ulcers and/or colitis
147 Increased sugar tolerance
148 (FEMALE) Menstrual disorders
149 (YOUNG GIRLS) Lack of menstrual function
           
  NA 1 2 3 GROUP 7E HYPERADRENAL
150 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 (FEMALE) Hair growth on face or body
155 Sugar in urine (not diabetes)
156 (FEMALE) Masculine tendencies
           
  NA 1 2 3 GROUP 7F HYPOADRENAL
157 Weakness and/or dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails weak and/or ridged
161 Tendency toward hives
162 Arthritic tendencies
163 Perspiration increase
164 Bowel disorders
165 Poor circulation
166 Swollen ankles
167 Crave salt
168 Brown spots or bronzing of skin
169 Allergies - tendency to asthma
170 Weakness after colds or influenza
171 Muscular and nervous exhaustion
172 Respiratory disorders
           
  NA 1 2 3 GROUP 8 FOUNDATIONAL ISSUES
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
           
  NA 1 2 3 FEMALE ONLY
200 Very easily fatigued
201 Premenstrual tension
202 Painful menses
203 Depressed feelings before menstruation
204 Excessive and prolonged menstruation
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 Long standing depression
           
  NA 1 2 3 MALE ONLY
213 Prostate trouble
214 Urination difficult or dribbling
215 Frequent night time urination
216 Depression
217 Pain on inside of legs or heels
218 Feeling of incomplete bowel evacuation
219 Lack of energy
220 Migrating aches and pains
221 Too easily tired
222 Avoids activity
223 Leg nervousness at night
224 Diminished sex drive

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