THE SYMPTOM SURVEY FORM

	  



Last Name:  
First Name:  
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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
(A)
107. Insomnia   0123
108. Nervousness   0123
109. Can't gain weight   0123
110. Intolerance to heat   0123
111. Highly emotional   0123
112. Flush easily   0123
113. Night sweats   0123
114. Thin, moist skin   0123
115. Inward trembling   0123
116. Heart palpitates   0123
117. Increased appetite without weight gain   0123
118. Pulse fast at rest   0123
119. Eyelids and face twitch   0123
120. Irritable and restless   0123
121. Can't work under pressure   0123

(B)
122. Increase in weight   0123
123. Decrease in appetite   0123
124. Fatigue easily   0123
125. Ringing in ears   0123
126. Sleepy during day   0123
127. Sensitive to cold   0123
128. Dry or scaly skin   0123
129. Constipation   0123
130. Mental sluggishness   0123
131. Hair coarse, falls out   0123
132. Headaches upon arising wear off during day   0123
133. Slow pulse, below 65   0123
134. Frequency of urination   0123
135. Impaired hearing   0123
136. Reduced initiative   0123

(C)
137. Failing memory   0123
138. Low blood pressure   0123
139. Increased sex drive   0123
140. Headaches, "splitting or rending" type   0123
141. Decreased sugar tolerance   0123

(D)
142. Abnormal thirst   0123
143. Bloating of abdomen   0123
144. Weight gain around hips or waist   0123
145. Sex drive reduced or lacking   0123
146. Tendency to ulcers, colitis   0123
147. Increased sugar tolerance   0123
148. Women: menstrual disorders   0123
149. Young girls: lack of menstrual function   0123

(E)
150. Dizziness   0123
151. Headaches   0123
152. Hot flashes   0123
153. Increased blood pressure   0123
154. Hair growth on face or body (female)   0123
155. Sugar in urine (not diabetes)   0123
156. Masculine tendencies (female)   0123

(F)
157. Weakness, dizziness   0123
158. Chronic fatigue   0123
159. Low blood pressure   0123
160. Nails weak, ridged   0123
161. Tendency to hives   0123
162. Arthritic tendencies   0123
163. Perspiration increase   0123
164. Bowel disorders   0123
165. Poor circulation   0123
166. Swollen ankles   0123
167. Crave salt   0123
168. Brown spots or bronzing of skin   0123
169. Allergies-tendency to asthma   0123
170. Weakness after colds, influenza   0123
171. Exhaustion-muscular and nervous   0123
172. Respiratory disorders   0123

Group 8
173. Apprehension 0123
174. Irritability  0123
175. Morbid fears 0123
176. Never seem to get well 0123
177. Forgetfulness 0123
178. Indigestion  0123
179. Poor Appetite 0123
180. Craving for sweets 0123
181. Muscular soreness 0123
182. Depression; feelings of dread 0123
183. Noise sensitivity 0123
184. Acoustic hallucinations 0123
185. Tendency to cry without reason 0123
186. Hair is coarse and/or thinning 0123
187. Weakness 0123
188. Fatigue 0123
189. Skin sensitive to touch 0123
190. Tendency towards hives 0123
191. Nervousness 0123
192. Headache 0123
193. Insomnia 0123
194. Anxiety 0123
195. Anorexia 0123
196. Inability to concentrate; confusion 0123
197. Frequent stuffy nose; sinus infections 0123
198. Allergy to some foods 0123
199. Loose joints 0123
   
FEMALE ONLY
200. Very easily fatigued 0123
201. Premenstrual tension 0123
202. Painful menses 0123
203. Depressed feelings before menstruation 0123
204. Menstruation excessive and prolonged 0123
205. Painful breasts 0123
206. Menstruate too frequently 0123
207. Vaginal discharge 0123
208. Hysterectomy/ovaries removed 0123
209. Menopausal hot flashes 0123
210. Menses scanty or missed 0123
211. Acne, worse at menses 0123
212. Depression of long standing 0123

MALE ONLY
213. Prostate trouble 0123
214. Urination difficult or dribbling 0123
215. Night urination frequent 0123
216. Depression 0123
217. Pain on inside of legs or heels 0123
218. Feeling of incomplete bowel evacuation 0123
219. Lack of energy 0123
220. Migrating aches and pains 0123
221. Tire too easily 0123
222. Avoids activity 0123
223. Leg nervousness at night 0123
224. Diminished sex drive 0123
IMPORTANT: Please list below the five main
health complaints you have in order of their
importance.
 1 
 2 
 3 
 4 
 5