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THE SYMPTOM SURVEY FORM


	  
Last Name: First Name: Address: Address: City: State: Zip: Home Phone: Work Phone: E-mail: Sex: Birthdate: Would you like your report via email If no, your report will be sent via USPS mail

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 between 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

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$50.00 US Funds for Symptom Survey Report OR
$125.00 US Funds for both Survey and Mineral Analysis

Mailing address for payment by check or money order:
Dr. Eva Urbaniak
4262 Whitman Ave N.
Seattle, WA 98103-7345

If you have questions for Doc Eva, please feel free to email her at docevaonline.com

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