SYMPTOM SURVEY FORM Patient_____________________________________________________ INSTRUCTIONS:

1. 2. 3. 4. 5. 6. 7. 21. 22. 23. 24. 25. 26. 27. 28. 42. 43. 44. 45. 46. 47. 48.

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

M/F

Date____________________

LEAVE THE QUESTION BLANK if the question does not apply to you. CIRCLE (1) for MILD symptoms (occurring once or twice a year). CIRCLE (2) for MODERATE symptoms (occurring several times a month). CIRCLE (3) for SEVERE symptoms (you are aware of it almost constantly)

Acid foods upset Get chilled often “Lump” in throat Dry mouth-eyes-nose Pulse speeds after meals Keyed up – fail to calm down Cuts heal slowly

8. 9. 10. 11. 12. 13. 14.

1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3

Gag easily Unable to relax; startles easily Extremities cold, clammy Strong light irritates Urine amount reduced Heart pounds after retiring “Nervous” stomach

GROUP TWO

3 3 3 3 3 3 3 3

Digestion rapid Vomiting frequent Hoarseness frequent Breathing irregular Pulse slow; feels irregular Gagging reflex slow Difficulty swallowing Constipation, diarrhea alternating

15. 16. 17. 18. 19. 20.

1 1 1 1 1 1

2 2 2 2 2 2

3 3 3 3 3 3

37. 38. 39. 40.

1 1 1 1

2 2 2 2

3 3 3 3

Appetite reduced Cold sweats often Fever easily raised Tingling, Nerve-like pains Staring, blinks little Sour stomach frequent

Joint stiffness after arising Muscle-leg-toe cramps at night “Butterfly” stomach, cramps Eyes or nose watery Eyes blink often Eyelids swollen, puffy Indigestion soon after meals Always seems hungry; feels “lightheaded” often

29. 30. 31. 32. 33. 34. 35. 36.

Eat when nervous Excessive appetite Hungry between meals Irritable before meals Get “shaky” if hungry Fatigue, eating relieves “Lightheaded” if meals delayed

49. 1 2 3 Heart palpitates if meals 53. 1 2 3 Crave candy or coffee missed or delayed in afternoon 50. 1 2 3 Afternoon headaches 54. 1 2 3 Moods of depression – 51. 1 2 3 Overeating sweets upsets “blues” or melancholy 52. 1 2 3 Awaken after few hours sleep 55. 1 2 3 Abnormal craving for – hard to get back to sleep sweets or snacks

56. 1 2 3 Hands and feet go to sleep easily, numbness 57. 1 2 3 Sigh frequently, “air 58. 1 2 3 Aware of “breathing heavily” 59. 1 2 3 High altitude discomfort 60. 1 2 3 Opens windows in closed room 61. 1 2 3 Susceptible to colds and fevers 62. 1 2 3 Afternoon yawner

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2

GROUP ONE

“Slow starter” Get “chilled” infrequently Perspire easily Circulation poor, sensitive to cold 41. 1 2 3 Subject to colds, asthma, bronchitis

GROUP THREE

GROUP FOUR 63. 1 2 3 Get “drowsy” often 64. 1 2 3 Swollen ankles worse at night 65. 1 2 3 Muscle cramps, worse during exercise; get “charley horses” 66. 1 2 3 Shortness of breath on exertion 67. 1 2 3 Dull pain in chest or ` radiating into left arm, worse on exertion

68. 1 2 3 Bruise easily, “black and blue” spots 69. 1 2 3 Tendency towards anemia 70. 1 2 3 “Nose bleeds” frequent 71. 1 2 3 Noises in head, or “ringing in the ears” 72. 1 2 3 Tension under breastbone or feeling of “tightness”, worse on exertion

83. 1 2 3 Feeling queasy; headache over eyes 84. 1 2 3 Greasy foods upset 85. 1 2 3 Stools light-colored 86. 1 2 3 Skin peels on soles of feet 87. 1 2 3 Pain between shoulder blades 88. 1 2 3 Use laxatives 89. 1 2 3 Stools alternate from soft to watery 90. 1 2 3 History of gallbladder attacks or gallstones

91. 1 2 3 Sneezing attacks 92. 1 2 3 Dreaming, nightmare type bad dreams 93. 1 2 3 Bad breath (halitosis) 94. 1 2 3 Milk products cause distress 95. 1 2 3 Sensitive to hot weather 96. 1 2 3 Burning or itching anus 97. 1 2 3 Crave sweets

GROUP FIVE

73. 74. 75. 76. 77. 78. 79. 80.

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3

Dizziness Dry skin Burning feet Blurred vision Itching skin and feet Excessive falling hair Frequent skin rashes Bitter, metallic taste in mouth in mornings 81. 1 2 3 Bowel movements painful or difficult 82. 1 2 3 Worrier, feels insecure

GROUP SIX 98. 1 2 3 Loss of taste for meat 99. 1 2 3 Lower bowel gas several hours after eating 100. 1 2 3 Burning stomach sensations, eating relieves

107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117.

1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3

118. 119. 120. 121.

1 1 1 1

2 2 2 2

3 3 3 3

122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132.

1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3

133. 134. 135. 136.

1 1 1 1

2 2 2 2

3 3 3 3

173. 174. 175. 176.

1 1 1 1

(A) Insomnia Nervousness Can’t gain weight Intolerance to heat Highly emotional Flush easily Night sweats Thin, moist skin ` Inward trembling Heart palpitates Increased appetite without weight gain Pulse fast at rest Eyelids and face twitch Irritable and restless Can’t work under pressure (B) Increase in weight Decrease in appetite Fatigue easily Ringing in ears Sleepy during day Sensitive to cold Dry or scaly skin Constipation Mental sluggishness Hair coarse, falls out Headaches upon arising, wear off during day Slow pulse, below 65 Frequency of urination Impaired hearing Reduced initiative

FEMALE ONLY 2 2 2 2

3 3 3 3

177. 1 2 3 178. 179. 180. 181.

1 1 1 1

2 2 2 2

3 3 3 3

182. 183. 184. 185.

1 1 1 1

2 2 2 2

3 3 3 3

Very easily fatigued Premenstrual tension Painful menses Depressed feelings before menstruation Menstruation excessive and prolonged Painful breasts Menstruate too frequently Vaginal discharge Hysterectomy/ovaries removed Menopausal hot flashes Menses scanty or missed Acne, worse at menses Depression of long standing

101. 1 2 3 Coated tongue 104. 1 2 3 Mucous colitis or 102. 1 2 3 Pass large amounts of 105. 1 2 3 Gas shortly after eating foul-smelling gas 106. 1 2 3 Stomach “bloating” 103. 1 2 3 Indigestion ½ - 1 hour after after eating eating; may be up to 3 – 4 hrs.

GROUP SEVEN

(C) Failing memory Low blood pressure Increased sex drive Headaches, “splitting or rending” type 141. 1 2 3 Decreased sugar tolerance

137. 138. 139. 140.

1 1 1 1

2 2 2 2

3 3 3 3

(D) 142. 1 2 3 Abnormal thirst 143. 1 2 3 Bloating of abdomen 144. 1 2 3 Weight gain around hips or waist 145. 1 2 3 Sex drive reduced or lacking 146. 1 2 3 Tendency toward ulcers, colitis 147. 1 2 3 Increased sugar tolerance 148. 1 2 3 Women: menstrual disorders 149. 1 2 3 Young girls: lack of menstrual function

(E) Dizziness Headaches Hot flashes Increased blood pressure Hair growth on face or body (female) 155. 1 2 3 Sugar in urine (not diabetes) 156. 1 2 3 Masculine tendencies (female)

150. 151. 152. 153. 154.

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2 2 2 2 2

3 3 3 3 3

157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168.

1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3

169. 1 2 3 170. 1 2 3 171. 1 2 3 172. 1 2 3

MALE ONLY

186. 1 2 3 Prostate trouble 187. 1 2 3 Urination difficult or dribbling 188. 1 2 3 Night urination frequent 189. 1 2 3 Depression 190. 1 2 3 Pain on inside of legs or heels 191. 1 2 3 Feeling of incomplete bowel evacuation 192. 1 2 3 Lack of energy 193. 1 2 3 Migrating aches and pains 194. 1 2 3 Tire too easily 195. 1 2 3 Avoids activity 196. 1 2 3 Leg nervousness at night 197. 1 2 3 Diminished sex drive

(F) Weakness, dizziness Chronic fatigue Low blood pressure Nails, weak, ridged Tendency toward hives Arthritic tendencies Perspiration increase Bowel disorders Poor circulation Swollen ankles Crave salt Brown spots or bronzing of skin Allergies – tendency to asthma Weakness after colds, influenza Exhaustion – muscular and nervous Respiratory disorders

IMPORTANT

Please list below the five main physical complaints you have in order of their importance: 1. __________________________ 2. __________________________ 3. __________________________ 4. __________________________ 5. __________________________