Symptom Survey Online Form

Name    
Phone        e-mail
Address       City 
State       Zip  
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