Symptom Survey Form

Nameyour full name

Doctoryour Physician's name

Today's Datetoday's date mm/dd/yy

Birth Datemm/dd/yy

Genderpick one!

MaleFemale

Please select the symptoms in which apply

Leave any items that don't apply BLANK

Group 1 Survey

	Mild	Mod.	Severe
1 Acid foods upset
2 Get chilled, often
3 Lump in throat
4 Dry mouth-eyes-nose
5 Pulse speeds after meals
6 Keyed up-fail to calm
7 Cuts heal 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 (intense, typically intermittent pain along the course of a nerve, especially in the head or face.)
19 Staring, blinks little
20 Sour stomach frequent

Please select the symptoms in which apply

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Group 2

	Mild	Mod.	Severe
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, puffy
27 Indigestion soon after meals
28 Always seems hungry; feels "lightheaded" 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

	Mild	Mod.	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 “Lightheaded” 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 the afternoons
54 Moods of depression “blues” or melancholy
55 Abnormal craving for sweets or snacks

Please select the symptoms in which apply

Leave any items that don't apply BLANK

Group 4

	Mild	Mod.	Severe
56 Hands 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 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; 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/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

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Group 5A

	Mild	Mod.	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 foods upset
85 Stools light-colored

Group 5B

	Poor	Average	Good
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

Please select the symptoms in which apply

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Group 6

	Mild	Mod.	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 ½ - hour after eating; may be up to 3-4 hours
104 Mucus colitis or “irratble bowel”
105 Gas shortly after eating
106 Stomach “bloating” after eating

Group 7A

	Mild	Mod.	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

	Mild	Mod.	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 up on arising wear off during day
133 Slow pulse, below 65
134 Frequency of urination
135 Impaired hearing
136 Reduced initiative

Please select the symptoms in which apply

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Group 7D

	Mild	Mod.	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: lacks of menstrual function

Group 7F

	Mild	Mod.	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
166 Swollen 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 Respirator disorders

Female Only

	Mild	Mod.	Severe
173 Very easily fatigued
174 Premenstrual tension
175 Painful menses
176 Depressed feelings before menstruation
177 Menstruation excessive and prolonged
178 Painful breasts
179 Menstruate too frequently
180 vaginal discharge
181 Hysterectomy/ovaries removed
182 Menopausal hot flashes
183 Menses scanty or missed
184 Acne, worse at menses
185 Depression of long standing

Male Only

	Mild	Mod.	Severe
186 Prostate trouble
187 Urination difficult or dribbling
188 Night urination frequent
189 Depression of long standing
190 Pain on inside of legs or heels
191 Feeling of incomplete bowel evacuation
192 Lack of energy
193 Migration aches and pains
194 Tire too easily
195 Avoids activity
196 Leg nervousness at night
197 Diminshed sex drive

TO THE PATIENT

Please list below the five main health complaints you have in order of their importance:

1.Health Complaints

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2.Health Complaints

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3.Health Complaints

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4.Health Complaints

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5.Health Complaints

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	Mild	Mod.	Severe
137 Failing memory
138 Low blood pressure increased sex drive
139 Increased Sex Drive
140 Headaches, “splitting or rending” type
141 Decreased sugar tolerance

	Mild	Mod.	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)

Symptom Survey Form

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