Symptom Survey Form

Instructions: Fill in only the circles which apply to you.

1-Mild symptoms (occurred once or twice last 6 months).

2-Moderate symptoms (occurred once or twice last month).

3-Severe symptoms (chronic, occurred once or twice last week).

Leave circles blank if they don’t apply to you!

Patient:

Email:

Doctor:

Date:

Birthday:

Approx Weight:

Sex:

Male Female

Vegetarian:

Yes No

Acid foods upset

1 2 3

Get chilled often

1 2 3

"Lump" in throat

1 2 3

Dry mouth-eyes-nose

1 2 3

Pulse speeds after meal

1 2 3

Keyed up - fail to calm

1 2 3

Cut heals slowly

1 2 3

Gag easily

1 2 3

Unable to relax; startles easily

1 2 3

Extremities cold, clammy

1 2 3

Strong light irritates

1 2 3

Urine amount reduced

1 2 3

Heart pounds after retiring

1 2 3

"Nervous" stomach

1 2 3

Appetite reduced

1 2 3

Cold sweats often

1 2 3

Fever easily raised

1 2 3

Neuralgia-like pains

1 2 3

Staring, blinks little

1 2 3

Sour stomach often

1 2 3

Joint stiffness on arising

1 2 3

Muscle-leg-toe cramps at night

1 2 3

"Butterfly" stomach, cramps

1 2 3

Eyes or nose watery

1 2 3

Eyes blink often

1 2 3

Eyelids swollen, puffy

1 2 3

Indigestion soon after meals

1 2 3

Alway seems hungry; feels "lightheaded" often

1 2 3

Digestion rapid

1 2 3

Vomiting frequent

1 2 3

Hoarseness frequent

1 2 3

Breathing irregular

1 2 3

Pulse slow; feels "irregular"

1 2 3

Gagging reflex slow

1 2 3

Difficulty swallowing

1 2 3

Constipation, diarrhea alternating

1 2 3

"Slow starter"

1 2 3

Get "chilled" infrequently

1 2 3

Perspire easily

1 2 3

Circulation poor, sensitive to cold

1 2 3

Subject to colds, asthma, bronchitis

1 2 3

Eat when nervous

1 2 3

Excessive appetite

1 2 3

Get "shaky" if hungry

1 2 3

Hungry between meals

1 2 3

Fatigue, eating relieves

1 2 3

"Lightheaded" if meals delayed

1 2 3

Heart palpitates if meals missed or delayed

1 2 3

Afternoon headaches

1 2 3

Overeating sweets upsets

1 2 3

Awaken after few hours sleep - hard to get back to sleep

1 2 3

Crave candy or coffee in afternoons

1 2 3

Moods of depression - "blues" or melancholy

1 2 3

Abnormal craving for sweets or snacks

1 2 3

Hands and feet go to sleep easily, numbness

1 2 3

Sigh frequently, "air hunger"

1 2 3

Aware of "breathing heavily"

1 2 3

High altitude discomfort

1 2 3

Opens windows in closed rooms

1 2 3

Susceptible to colds and fevers

1 2 3

Afternoon "yawner"

1 2 3

Get "drowsy" often

1 2 3

Swollen ankles, worse at night

1 2 3

Muscle cramps, worse during exercise; get "charley horses"

1 2 3

Shortness of breath on exertion

1 2 3

Dull pain in chest or radiating into left arm, worse on exertion

1 2 3

Bruise easily, "black and blue" spots

1 2 3

Tendency to anemia

1 2 3

"Nose bleeds" frequent

1 2 3

Noises in head, or "ringing in ears"

1 2 3

Tension under the breastbone, or feeling of "tightness", worse on exertion

1 2 3

Dizziness

1 2 3

Dry Skin

1 2 3

Burning feet

1 2 3

Blurred vision

1 2 3

Itching skin and feet

1 2 3

Excessive falling hair

1 2 3

Frequent skin rashes

1 2 3

Bitter, metallic taste in mouth in mornings

1 2 3

Bowel movements painful or difficult

1 2 3

Worrier, feels insecure

1 2 3

Feeling queasy; headache over eyes

1 2 3

Greasy foods upset

1 2 3

Stools light colored

1 2 3

Skin peels on foot soles

1 2 3

Pain between shoulder blades

1 2 3

Use laxatives

1 2 3

Stools alternate from soft to watery

1 2 3

History of gallbladder attacks or gallstones

1 2 3

Sneezing attacks

1 2 3

Dreaming, nightmare type bad dreams

1 2 3

Bad breath (halitosis)

1 2 3

Milk products cause distress

1 2 3

Sensitive to hot weather

1 2 3

Burning or itching anus

1 2 3

Crave sweets

1 2 3

Loss of taste for meat

1 2 3

Lower bowel gas several hours after eating

1 2 3

Burning stomach sensations, eating relieves

1 2 3

Coated tongue

1 2 3

Pass large amounts of foul-smelling gas

1 2 3

Indigestion 1/2-1 hour after eating; may be up to 3-4 hrs.

1 2 3

Mucous colitis or "irritable bowel"

1 2 3

Gas shortly after eating

1 2 3

Stomach "bloating" after eating

1 2 3

Insomnia

1 2 3

Nervousness

1 2 3

Can't gain weight

1 2 3

Intolerance to heat

1 2 3

Highly emotional

1 2 3

Flush easily

1 2 3

Night sweats

1 2 3

Thin, moist skin

1 2 3

Inward trembling

1 2 3

Heart palpitates

1 2 3

Increased appetite without weight gain

1 2 3

Pulse fast at rest

1 2 3

Eyelids and face twitch

1 2 3

Irritable and restless

1 2 3

Can't work under pressure

1 2 3

Increase in weight

1 2 3

Decrease in appetite

1 2 3

Fatigue easily

1 2 3

Ringing in ears

1 2 3

Sleepy during day

1 2 3

Sensitive to cold

1 2 3

Dry or scaly skin

1 2 3

Constipation

1 2 3

Mental sluggishness

1 2 3

Hair coarse, falls out

1 2 3

Headaches upon arising, wear off during day

1 2 3

Slow pulse, below 65

1 2 3

Frequency of urination

1 2 3

Impaired hearing

1 2 3

Reduced initiative

1 2 3

Failing memory

1 2 3

Low blood pressure

1 2 3

Increased sex drive

1 2 3

Headaches, "splitting or rending" type

1 2 3

Decreased sugar tolerance

1 2 3

Abnormal thirst

1 2 3

Bloating of abdomen

1 2 3

Weight gain around hips or waist

1 2 3

Sex drive reduced or lacking

1 2 3

Tendency to ulcers, colitis

1 2 3

Increased sugar tolerance

1 2 3

Women: menstrual disorders

1 2 3

Young girls: lack of menstrual function

1 2 3

Dizziness

1 2 3

Headaches

1 2 3

Hot flashes

1 2 3

Increased blood pressure

1 2 3

Hair growth on face or body (female)

1 2 3

Sugar in urine (not diabetes)

1 2 3

Masculine tendencies (female)

1 2 3

Weakness, dizziness

1 2 3

Chronic fatigue

1 2 3

Low blood pressure

1 2 3

Nails weak, ridged

1 2 3

Tendency to hives

1 2 3

Arthritic tendencies

1 2 3

Perspiration increase

1 2 3

Bowel disorders

1 2 3

Poor circulation

1 2 3

Swollen ankles

1 2 3

Crave salt

1 2 3

Brown spots or bronzing of skin

1 2 3

Allergies - tendency to asthma

1 2 3

Weakness after colds, influenza

1 2 3

Exhaustion - muscular and nervous

1 2 3

Respiratory disorders

1 2 3

Apprehension

1 2 3

Irritability

1 2 3

Morbid fears

1 2 3

Never seems to get well

1 2 3

Forgetfulness

1 2 3

Indigestion

1 2 3

Poor appetite

1 2 3

Craving for sweets

1 2 3

Muscular soreness

1 2 3

Depression; feelings of dread

1 2 3

Noise sensitivity

1 2 3

Acoustic hallucinations

1 2 3

Tendency to cry without reason

1 2 3

Hair is coarse and/or thinning

1 2 3

Weakness

1 2 3

Fatigue

1 2 3

Skin sensitive to touch

1 2 3

Tendency toward hives

1 2 3

Nervousness

1 2 3

Headache

1 2 3

Insomnia

1 2 3

Anxiety

1 2 3

Anorexia

1 2 3

Inability to concentrate; confusion

1 2 3

Frequent stuffy nose; sinus infections

1 2 3

Allergy to some foods

1 2 3

Loose joints

1 2 3

Female Only: Very easily fatigued

1 2 3

Premenstrual tension

1 2 3

Painful menses

1 2 3

Depressed feelings before menstruation

1 2 3

Menstruation excessive and prolonged

1 2 3

Painful breasts

1 2 3

Menstruate too frequently

1 2 3

Vaginal discharge

1 2 3

Hysterectomy/ovaries removed

Yes

Menopausal hot flashes

1 2 3

Menses scanty or missed

1 2 3

Acne, worse at menses

1 2 3

Depression of long standing

1 2 3

Male Only: Prostate trouble

1 2 3

Urination difficult or dribbling

1 2 3

Night urination frequent

1 2 3

Depression

1 2 3

Pain on inside of legs or heels

1 2 3

Feeling of incomplete bowel evacuation

1 2 3

Lack of energy

1 2 3

Migrating aches and pains

1 2 3

Tire too easily

1 2 3

Avoids activity

1 2 3

Leg nervousness at night

1 2 3

Diminished sex drive

1 2 3

List the five main complaints you have in the orde of their importance:

Symptom Survey Form

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