Symptom Survey

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Patient Name (First and Last)

Date

Birth Date

Approx. Weight (lbs)

Sex

Male Female

Vegetarian

Yes No

For each symptom that applies to you, choose how often it occurs. Leave it blank if it does not apply.

Mild = occurred once or twice in the last 6 months
Moderate = once or twice in the last month
Severe = chronic, once or twice a week

GROUP 1

1. Acid foods upset

Mild Moderate Severe

2. Get chilled often

Mild Moderate Severe

3. "Lump" in throat

Mild Moderate Severe

4. Dry mouth-eyes-nose

Mild Moderate Severe

5. Pulse speeds after meal

Mild Moderate Severe

6. Keyed up - fail to calm

Mild Moderate Severe

7. Cut heals slowly

Mild Moderate Severe

8. Gag easily

Mild Moderate Severe

9. Unable to relax; startles easily

Mild Moderate Severe

10. Extremities cold, clammy

Mild Moderate Severe

11. Strong light irritates

Mild Moderate Severe

12. Urine amount reduced

Mild Moderate Severe

13. Heart pounds after retiring

Mild Moderate Severe

14. "Nervous" stomach

Mild Moderate Severe

15. Appetite reduced

Mild Moderate Severe

16. Cold sweats often

Mild Moderate Severe

17. Fever easily raised

Mild Moderate Severe

18. Neuralgia-like pains

Mild Moderate Severe

19. Staring, blinks little

Mild Moderate Severe

20. Sour stomach often

Mild Moderate Severe

GROUP 2

21. Joint stiffness on arising

Mild Moderate Severe

22. Muscle-leg-toe cramps at night

Mild Moderate Severe

23. "Butterfly" stomach, cramps

Mild Moderate Severe

24. Eyes or nose watery

Mild Moderate Severe

25. Eyes blink often

Mild Moderate Severe

26. Eyelids swollen, puffy

Mild Moderate Severe

27. Indigestion soon after meals

Mild Moderate Severe

28. Always seems hungry; feels "lightheaded" often

Mild Moderate Severe

29. Digestion rapid

Mild Moderate Severe

30. Vomiting frequent

Mild Moderate Severe

31. Hoarseness frequent

Mild Moderate Severe

32. Breathing irregular

Mild Moderate Severe

33. Pulse slow; feels "irregular"

Mild Moderate Severe

34. Gagging reflex slow

Mild Moderate Severe

35. Difficulty swallowing

Mild Moderate Severe

36. Constipation, diarrhea alternating

Mild Moderate Severe

37. "Slow starter"

Mild Moderate Severe

38. Get "chilled" infrequently

Mild Moderate Severe

39. Perspire easily

Mild Moderate Severe

40. Circulation poor, sensitive to cold

Mild Moderate Severe

41. Subject to colds, asthma, bronchitis

Mild Moderate Severe

GROUP 3

42. Eat when nervous

Mild Moderate Severe

43. Excessive appetite

Mild Moderate Severe

44. Hungry between meals

Mild Moderate Severe

45. Irritable before meals

Mild Moderate Severe

46. Get "shaky" if hungry

Mild Moderate Severe

47. Fatigue, eating relieves

Mild Moderate Severe

48. "Lightheaded" if meals delayed

Mild Moderate Severe

49. Heart palpitates if meals missed or delayed

Mild Moderate Severe

50. Afternoon headaches

Mild Moderate Severe

51. Overeating sweets upsets

Mild Moderate Severe

52. Awaken after few hours sleep - hard to get back to sleep

Mild Moderate Severe

53. Crave candy or coffee in afternoons

Mild Moderate Severe

54. Moods of depression - "blues" or melancholy

Mild Moderate Severe

55. Abnormal craving for sweets or snacks

Mild Moderate Severe

GROUP 4

56. Hands and feet go to sleep easily, numbness

Mild Moderate Severe

57. Sigh frequently, "air hunger"

Mild Moderate Severe

58. Aware of "breathing heavily"

Mild Moderate Severe

59. High altitude discomfort

Mild Moderate Severe

60. Opens windows in closed rooms

Mild Moderate Severe

61. Susceptible to colds and fevers

Mild Moderate Severe

62. Afternoon "yawner"

Mild Moderate Severe

63. Get "drowsy" often

Mild Moderate Severe

64. Swollen ankles, worse at night

Mild Moderate Severe

65. Muscle cramps, worse during exercise; get "charley horses"

Mild Moderate Severe

66. Shortness of breath on exertion

Mild Moderate Severe

67. Dull pain in chest or radiating into left arm, worse on exertion

Mild Moderate Severe

68. Bruise easily, "black and blue" spots

Mild Moderate Severe

69. Tendency to anemia

Mild Moderate Severe

70. "Nose bleeds" frequent

Mild Moderate Severe

71. Noises in head, or "ringing in ears"

Mild Moderate Severe

72. Tension under the breastbone, or feeling of "tightness", worse on exertion

Mild Moderate Severe

GROUP 5

73. Dizziness

Mild Moderate Severe

74. Dry skin

Mild Moderate Severe

75. Burning feet

Mild Moderate Severe

76. Blurred vision

Mild Moderate Severe

77. Itching skin and feet

Mild Moderate Severe

78. Excessive falling hair

Mild Moderate Severe

79. Frequent skin rashes

Mild Moderate Severe

80. Bitter, metallic taste in mouth in mornings

Mild Moderate Severe

81. Bowel movements painful or difficult

Mild Moderate Severe

82. Worrier, feels insecure

Mild Moderate Severe

83. Feeling queasy; headache over eyes

Mild Moderate Severe

84. Greasy foods upset

Mild Moderate Severe

85. Stools light colored

Mild Moderate Severe

86. Skin peels on foot soles

Mild Moderate Severe

87. Pain between shoulder blades

Mild Moderate Severe

88. Use laxatives

Mild Moderate Severe

89. Stools alternate from soft to watery

Mild Moderate Severe

90. History of gallbladder attacks or gallstones

Mild Moderate Severe

91. Sneezing attacks

Mild Moderate Severe

92. Dreaming, nightmare type bad dreams

Mild Moderate Severe

93. Bad breath (halitosis)

Mild Moderate Severe

94. Milk products cause distress

Mild Moderate Severe

95. Sensitive to hot weather

Mild Moderate Severe

96. Burning or itching anus

Mild Moderate Severe

97. Crave sweets

Mild Moderate Severe

GROUP 6

98. Loss of taste for meat

Mild Moderate Severe

99. Lower bowel gas several hours after eating

Mild Moderate Severe

100. Burning stomach sensations, eating relieves

Mild Moderate Severe

101. Coated tongue

Mild Moderate Severe

102. Pass large amounts of foul-smelling gas

Mild Moderate Severe

103. Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs.

Mild Moderate Severe

104. Mucous colitis or "irritable bowel"

Mild Moderate Severe

105. Gas shortly after eating

Mild Moderate Severe

106. Stomach "bloating" after eating

Mild Moderate Severe

GROUP 7A

107. Insomnia

Mild Moderate Severe

108. Nervousness

Mild Moderate Severe

109. Can't gain weight

Mild Moderate Severe

110. Intolerance to heat

Mild Moderate Severe

111. Highly emotional

Mild Moderate Severe

112. Flush easily

Mild Moderate Severe

113. Night sweats

Mild Moderate Severe

114. Thin, moist skin

Mild Moderate Severe

115. Inward trembling

Mild Moderate Severe

116. Heart palpitates

Mild Moderate Severe

117. Increased appetite without weight gain

Mild Moderate Severe

118. Pulse fast at rest

Mild Moderate Severe

119. Eyelids and face twitch

Mild Moderate Severe

120. Irritable and restless

Mild Moderate Severe

121. Can't work under pressure

Mild Moderate Severe

GROUP 7B

122. Increase in weight

Mild Moderate Severe

123. Decrease in appetite

Mild Moderate Severe

124. Fatigue easily

Mild Moderate Severe

125. Ringing in ears

Mild Moderate Severe

126. Sleepy during day

Mild Moderate Severe

127. Sensitive to cold

Mild Moderate Severe

128. Dry or scaly skin

Mild Moderate Severe

129. Constipation

Mild Moderate Severe

130. Mental sluggishness

Mild Moderate Severe

131. Hair coarse, falls out

Mild Moderate Severe

132. Headaches upon arising, wear off during day

Mild Moderate Severe

133. Slow pulse, below 65

Mild Moderate Severe

134. Frequency of urination

Mild Moderate Severe

135. Impaired hearing

Mild Moderate Severe

136. Reduced initiative

Mild Moderate Severe

GROUP 7C

137. Failing memory

Mild Moderate Severe

138. Low blood pressure

Mild Moderate Severe

139. Increased sex drive

Mild Moderate Severe

140. Headaches, "splitting or rending" type

Mild Moderate Severe

141. Decreased sugar tolerance

Mild Moderate Severe

GROUP 7D

142. Abnormal thirst

Mild Moderate Severe

143. Bloating of abdomen

Mild Moderate Severe

144. Weight gain around hips or waist

Mild Moderate Severe

145. Sex drive reduced or lacking

Mild Moderate Severe

146. Tendency to ulcers, colitis

Mild Moderate Severe

147. Increased sugar tolerance

Mild Moderate Severe

148. Women: menstrual disorders

Mild Moderate Severe

149. Young girls: lack of menstrual function

Mild Moderate Severe

GROUP 7E

150. Dizziness

Mild Moderate Severe

151. Headaches

Mild Moderate Severe

152. Hot flashes

Mild Moderate Severe

153. Increased blood pressure

Mild Moderate Severe

154. Hair growth on face or body (female)

Mild Moderate Severe

155. Sugar in urine (not diabetes)

Mild Moderate Severe

156. Masculine tendencies (female)

Mild Moderate Severe

GROUP 7F

157. Weakness, dizziness

Mild Moderate Severe

158. Chronic fatigue

Mild Moderate Severe

159. Low blood pressure

Mild Moderate Severe

160. Nails weak, ridged

Mild Moderate Severe

161. Tendency to hives

Mild Moderate Severe

162. Arthritic tendencies

Mild Moderate Severe

163. Perspiration increase

Mild Moderate Severe

164. Bowel disorders

Mild Moderate Severe

165. Poor circulation

Mild Moderate Severe

166. Swollen ankles

Mild Moderate Severe

167. Crave salt

Mild Moderate Severe

168. Brown spots or bronzing of skin

Mild Moderate Severe

169. Allergies - tendency to asthma

Mild Moderate Severe

170. Weakness after colds, influenza

Mild Moderate Severe

171. Exhaustion - muscular and nervous

Mild Moderate Severe

172. Respiratory disorders

Mild Moderate Severe

GROUP 8

173. Apprehension

Mild Moderate Severe

174. Irritability

Mild Moderate Severe

175. Morbid fears

Mild Moderate Severe

176. Never seems to get well

Mild Moderate Severe

177. Forgetfulness

Mild Moderate Severe

178. Indigestion

Mild Moderate Severe

179. Poor appetite

Mild Moderate Severe

180. Craving for sweets

Mild Moderate Severe

181. Muscular soreness

Mild Moderate Severe

182. Depression; feelings of dread

Mild Moderate Severe

183. Noise sensitivity

Mild Moderate Severe

184. Acoustic hallucinations

Mild Moderate Severe

185. Tendency to cry without reason

Mild Moderate Severe

186. Hair is coarse and/or thinning

Mild Moderate Severe

187. Weakness

Mild Moderate Severe

188. Fatigue

Mild Moderate Severe

189. Skin sensitive to touch

Mild Moderate Severe

190. Tendency toward hives

Mild Moderate Severe

191. Nervousness

Mild Moderate Severe

192. Headache

Mild Moderate Severe

193. Insomnia

Mild Moderate Severe

194. Anxiety

Mild Moderate Severe

195. Anorexia

Mild Moderate Severe

196. Inability to concentrate; confusion

Mild Moderate Severe

197. Frequent stuffy nose; sinus infections

Mild Moderate Severe

198. Allergy to some foods

Mild Moderate Severe

199. Loose joints

Mild Moderate Severe

FEMALE ONLY

200. Very easily fatigued

Mild Moderate Severe

201. Premenstrual tension

Mild Moderate Severe

202. Painful menses

Mild Moderate Severe

203. Depressed feelings before menstruation

Mild Moderate Severe

204. Menstruation excessive and prolonged

Mild Moderate Severe

205. Painful breasts

Mild Moderate Severe

206. Menstruate too frequently

Mild Moderate Severe

207. Vaginal discharge

Mild Moderate Severe

208. Hysterectomy / ovaries removed

Mild Moderate Severe

209. Menopausal hot flashes

Mild Moderate Severe

210. Menses scanty or missed

Mild Moderate Severe

211. Acne, worse at menses

Mild Moderate Severe

212. Depression of long standing

Mild Moderate Severe

MALE ONLY

213. Prostate trouble

Mild Moderate Severe

214. Urination difficult or dribbling

Mild Moderate Severe

215. Night urination frequent

Mild Moderate Severe

216. Depression

Mild Moderate Severe

217. Pain on inside of legs or heels

Mild Moderate Severe

218. Feeling of incomplete bowel evacuation

Mild Moderate Severe

219. Lack of energy

Mild Moderate Severe

220. Migrating aches and pains

Mild Moderate Severe

221. Tire too easily

Mild Moderate Severe

222. Avoids activity

Mild Moderate Severe

223. Leg nervousness at night

Mild Moderate Severe

224. Diminished sex drive

Mild Moderate Severe

Your Main Complaints

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

Complaint 1 (most important)

Complaint 2

Complaint 3

Complaint 4

Complaint 5

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