Symptom Survey Form

Patient name: ____________________________________

Date of Birth: ____________ Height: _______Weight: ______

This will help you to remember what symptoms you have when you can’t remember (that’s called psychic amnesia by the way).

Instructions: Number the boxes that apply to you. Use (1) for MILD symptoms (occur once or twice a month), (2) for MODERATE symptoms (occur several times a month), and (3) for SEVERE symptoms (you are aware of almost constantly). We are focusing only on those issues that you have been experiencing in the last SIX months. If there are symptoms that you have experienced in the past, please mark that box with the letters (Hx) which means historically experienced. If you can remember the approximate year, go ahead and write that after the symptom.

GROUP ONE: (Sympathetic Dominance)

1. Acid foods upset
2. Gets chilled, often
3. “Lump” in throat
4. Dry mouth-eyes-nose
5. Pulse speeds after meal
6. Keyed up – fail to calm
7. Cuts heal slowly
8. Gags easily
9. Unable to relax, startles easily
10. Extremities cold, clammy
11. Strong light irritates
12. Urine amount reduced
13. Heart pounds after retiring
14. “Nervous” stomach
15. Appetite reduced
16. Cold sweats often
17. Fever easily raised
18. Neuralgia-like pains
19. Staring, blinks little
20. Sour stomach frequent

GROUP TWO: (Parasympathetic Dominance)

21. Joint stiffness after arising
22. Muscle-leg-toe cramps at night
23. “Butterfly” stomach, cramps
24. Eyes or nose watery
25. Eyes blink often
26. Eyelids swollen, puffy
27. Indigestion soon after meals
28. Always seem hungry; feels “lightheaded” often
29. Digestion rapid
30. Vomiting frequent
31. Hoarseness frequent
32. Breathing irregular
33. Pulse slow; feels “irregular”
34. Gagging reflex slow
35. Difficulty swallowing
36. Constipation, diarrhea alternating
37. “Slow starter”
38. Gets “chilled” infrequently
39. Perspires easily
40. Circulation poor, sensitive to cold
41. Subject to colds, asthma, bronchitis

GROUP THREE (Sugar Handling)

42. Eats when nervous
43. Excessive appetite
44. Hungry between meals
45. Irritable before meals
46. Gets “shaky” if hungry
47. Fatigue, eating relieves
48. “Lightheaded” if meals delayed
49. Heart palpitates if meals missed or delayed
50. Afternoon headaches
51. Overeating sweets upsets
52. Awaken after few hours sleep-hard to get back to sleep
53. Craves candy or coffee in afternoons
54. Moods of depression-”blues” or melancholy
55. Abnormal craving for sweets or snacks

GROUP FOUR (Cardiovascular)

56. Hands and feet go to sleep easily, numbness
57. Sighs frequently, “air hunger”
58. Aware of “breathing heavily”
59. High altitude discomfort
60. Opens windows in closed room
61. Susceptible to colds and fevers
62. Afternoon “yawner”
63. Gets “drowsy” often
64. Swollen ankles worse at night
65. Muscle cramps, worse during exercise; gets “charley horses”
66. Shortness of breath on exertion
67. Dull pain in chest or radiating into left arm, worse on exertion
68. Bruises easily, “black and blue” spots
69. Tendency to anemia
70. “Nose bleeds” frequent
71. Noises in head, or “ringing in ears”
72. Tension under the breastbone, or feeling of “tightness”  worse on exertion

GROUP FIVE (Liver and Gallbladder)

73. Dizziness
74. Dry skin
75. Burning feet
76. Blurred vision
77. Itching skin and feet
78. Excessive falling hair
79. Frequent skin rashes
80. Bitter, metallic taste in mouth in mornings
81. Bowel movements painful or difficult
82. Worrier, feels insecure
83. Feeling queasy; headache over eyes
84. Greasy foods upset
85. Stools light-colored
86. Skin peels on foot soles
87. Pain between shoulder blades
88. Uses laxatives
89. Stools alternate from soft to watery
90. History of gallbladder attacks or gallstones
91. Sneezing attacks
92. Dreaming, nightmare type bad dreams
93. Bad breath (halitosis)
94. Milk products cause distress
95. Sensitive to hot weather
96. Burning or itching anus
97. Craves sweets

GROUP SIX (Digestion)

98. Loss of taste for meat
99. Lower bowel gas several hours after eating
100. Burning stomach sensations, eating relieves
101. Coated tongue
102. Pass large amounts of foul-smelling gas
103. Indigestion 1/2 – 1 hour after eating but sometimes up to 3-4 hours
104. Mucous colitis or “irritable bowel”
105. Gas shortly after eating
106. Stomach “bloating” after eating

GROUP SEVEN (A)  (Endocrine-Hyperthyroid)

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

GROUP SEVEN (B) (Endocrine-Hypothyroid)

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

GROUP SEVEN ( C ) (Endocrine-Hyperpituitary)

137. Failing memory
138. Low blood pressure
139. Increased sex drive
140. Headaches, “splitting or rendering” type
141. Decreased sugar tolerance

GROUP SEVEN (D) (Endocrine-Hypopituitary)

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

GROUP SEVEN (E)  (Endocrine-Hyperadrenal)

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

GROUP SEVEN (F)  (Endocrine-Hypoadrenal)

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

GROUP EIGHT (B-Complex Deficiencies–Foundational Issues)

173. Apprehension
174. Irritability
175. Morbid fears
176. Never seems to get well
177. Forgetfulness
178. Indigestion
179. Poor appetite
180. Craving for sweets
181. Muscular soreness
182. Depression; feelings of dread
183. Noise sensitivity
184. Acoustic hallucinations
185. Tendency to cry without reason
186. Hair is coarse and/or thinning
187. Weakness
188. Fatigue
189. Skin sensitive to touch
190. Tendency toward hives
191. Nervousness
192. Headache
193. Insomnia
194. Anxiety
195. Anorexia
196. Inability to concentrate; confusion
197. Frequent stuffy nose; sinus infections
198. Allergy to some foods
199. Loose joints


200. Very easily fatigued
201. Premenstrual tension
202. Painful menses
203. Menstruates too frequently
204. Vaginal discharge
205. Hysterectomy/ovaries removed
206. Menopausal hot flashes
207. Menses scanty or missed
208. Acne, worse at menses
209. Depression of long standing


210.  Prostate trouble
211.  Urination difficult or dribbling
212.  Night urination frequent
213.  Depression
214. Pain on inside of legs or heels
215. Feeling of incomplete bowel evacuation
216. Lack of energy
217. Migrating aches and pains
218. Tires too easily
219. Avoids activity
220. Leg nervousness at night
221. Diminished sex drive

Please list below the five main physical complaints you have in order of their importance to you.


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