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

Restore
revive
get back to health

menu

links

Join our email list!

Symptom Survey Form

Restorereviveget back to health

menu

links

Join our email list!

Restore
revive
get back to health