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INSTRUCTIONS: Select the number that applies for each question
(0) Does not apply - no symptom
(1) for MILD symptoms (occur once or twice a year)
(2) for MODERATE symptoms (occur several times a year)
(3) for SEVERE symptoms (you are aware of it almost constantly)
Group 1
1. Acid foods upset 0123
2. Get chilled, often 0123
3. "Lump" in throat 0123
4. Dry mouth-eyes-nose 0123
5. Pulse speeds after meals 0123
6. Keyed up - fail to calm 0123
7. Cuts heal slowly 0123
8. Gag easily 0123
9. Unable to relax; startles easily 0123
10. Extremities cold, clammy 0123
11. Strong light irritates 0123
12. Urine amount reduced 0123
13. Heart pounds after retiring 0123
14. "Nervous" stomach 0123
15. Appetite reduced 0123
16. Cold Sweats often 0123
17. Fever easily raised 0123
18. Neuralgia-like pains 0123
19. Staring, blinks little 0123
20. Sour stomach frequent 0123
Group 2
21. Joint stiffness after arising 0123
22. Muscle-leg-toe cramps at night 0123
23. "Butterfly" stomach, cramps 0123
24. Eyes or nose watery 0123
25. Eyes blink often 0123
26. Eyelids swollen, puffy 0123
27. Indigestion soon after meals 0123
28. Always seem hungry; feels "lightheaded" often 0123
29. Digestion rapid 0123
30. Vomiting frequent 0123
31. Hoarseness frequent 0123
32. Breathing irregular 0123
33. Pulse slow; feels "irregular" 0123
34. Gagging reflex slow 0123
35. Difficulty swallowing 0123
36. Constipation, diarrhea alternating 0123
37. "Slow starter" 0123
38. Get "chilled" infrequently 0123
39. Perspire easily 0123
40. Circulation poor, sensitive to cold 0123
41. Subject to colds, asthma, bronchitis 0123
Group 3
42. Eat when nervous 0123
43. Excessive appetite 0123
44. Hungry beteen meals 0123
45. Irritable before meals 0123
46. Get "shaky" if hungry 0123
47. Fatigue, eating relieves 0123
48. "Lightheaded" if meals missed or delayed 0123
49. Heart palpitates if meals delayed 0123
50. Afternoon headaches 0123
51. Overeating sweets upsets 0123
52. Awaken after few hours sleep-hard to get back to sleep 0123
53. Crave candy or coffee in afternoons 0123
54. Moods of depression-"blues" or melancholy 0123
55. Abnormal craving for sweets or snacks 0123
Group 4
56. Hands and feet go to sleep easily, numbness 0123
57. Sigh frequently, "air hunger" 0123
58. Aware of "breathing heavily" 0123
59. High altitude discomfort 0123
60. Opens windows in closed room 0123
61. Susceptible to colds and fevers 0123
62. Afternoon "yawner" 0123
63. Get "drowsy" often 0123
64. Swollen ankles worse at night 0123
65. Muscle cramps, worse during exercise; get "charley horses" 0123
66. Shortness of breath on exertion 0123
67. Dull pain in chest or radiating into left arm, worse on exertion 0123
68. Bruise easily, "black/blue" spots 0123
69. Tendency to anemia 0123
70. "Nose bleeds" frequent 0123
71. Noises in head or "ringing in ears" 0123
72. Tension under the breastbone, or feeling of "tightness", worse on exertion 0123
Group 5
73. Dizziness 0123
74. Dry skin 0123
75. Burning feet 0123
76. Blurred vision 0123
77. Itching skin and feet 0123
78. Excessive falling hair 0123
79. Frequent skin rashes 0123
80. Bitter, metallic taste in mouth in mornings 0123
81. Bowel movements painful or difficult 0123
82. Worrier, feels insecure 0123
83. Feeling queasy; headache over eyes 0123
84. Greasy foods upset 0123
85. Stools light-colored 0123
86. Skin peels on foot soles 0123
87. Pain between shoulder blades 0123
88. Use laxatives 0123
89. Stools alternate from soft to watery 0123
90. History of gallbladder attacks or gallstones 0123
91. Sneezing attacks 0123
92. Dreaming, nightmare type bad dreams 0123
93. Bad breath (halitosis) 0123
94. Milk products cause distress 0123
95. Sensitive to hot weather 0123
96. Burning or itching anus 0123
97. Crave sweets 0123
Group 6
98. Loss of taste for meat 0123
99. Lower bowel gas several hours after eating 0123
100. Burning stomach sensations, eating relieves 0123
101. Coated tongue 0123
102. Pass large amounts of foul-smelling gas 0123
103. Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs. 0123
104. Mucus colitis or "irritable bowel" 0123
105. Gas shortly after eating 0123
106. Stomach "bloating" after eating 0123
Group 7
