Symptom Survey Form

Please Select The Appropriate Option--MILD for symptoms that occur once or twice a year, MODERATE for symptoms that occur several times a year, and SEVERE for symptoms which you are aware of almost constantly.

Name: Sex:   DOB: Address: City: State: Zip: Email:

~Group One~ 1.) Acid food upset N/A Mild Moderate Severe 2.) "Lump in throat" N/A Mild Moderate Severe 3.) Keyed up - fail to calm N/A Mild Moderate Severe 4.) Gag easily N/A Mild Moderate Severe 5.) Extremities cold, clammy N/A Mild Moderate Severe 6.) Sour stomach frequent N/A Mild Moderate Severe ~Group Two~ 7.) Indigestion soon after meals N/A Mild Moderate Severe 8.) Constipation, diarrhea alternating N/A Mild Moderate Severe 9.) "Slow starter" N/A Mild Moderate Severe 10.) Perspire easily N/A Mild Moderate Severe 11.) Subject to colds, asthma, bronchitis N/A Mild Moderate Severe ~Group Three~ 12.) Hungry between meals N/A Mild Moderate Severe 13.) Irritable before meals N/A Mild Moderate Severe 14.) Get "shaky" if hungry N/A Mild Moderate Severe 15.) Awaken after few hours sleep-hard to get back to sleep N/A Mild Moderate Severe 16.) Crave candy or coffee in afternoons N/A Mild Moderate Severe 17.) Moods of depression-"blues" or melancholy N/A Mild Moderate Severe 18.) Abnormal craving for sweets or snacks N/A Mild Moderate Severe ~Group Four~ 19.) Sigh frequently, "air hunger" N/A Mild Moderate Severe 20.) Susceptible to colds and fevers N/A Mild Moderate Severe 21.) Afternoon "yawner" N/A Mild Moderate Severe 22.) Get "drowsy" often N/A Mild Moderate Severe 23.) Bruise easily, "black and blue" spots N/A Mild Moderate Severe ~Group Five~ 24.) Dry skin N/A Mild Moderate Severe 25.) Bitter, metallic taste in mouth in mornings N/A Mild Moderate Severe 26.) Greasy foods upset N/A Mild Moderate Severe 27.) Stools light colored N/A Mild Moderate Severe 28.) Pain between shoulder blades N/A Mild Moderate Severe 29.) Bad breath (halitosis) N/A Mild Moderate Severe 30.) Milk products cause distress N/A Mild Moderate Severe 31.) Sensitive to hot weather N/A Mild Moderate Severe 32.) Burning or itching anus N/A Mild Moderate Severe 33.) Crave sweets N/A Mild Moderate Severe ~Group Six~ 34.) Lower bowel gas several hours after eating N/A Mild Moderate Severe 35.) Burning stomach sensation, eating relieves N/A Mild Moderate Severe 36.) Coated tongue (white) N/A Mild Moderate Severe 37.) Pass large amounts of foul-smelling gas N/A Mild Moderate Severe 38.) Gas shortly after eating N/A Mild Moderate Severe 39.) Stomach "bloating" after eating N/A Mild Moderate Severe ~Group Seven~ (A) 40.) Insomnia N/A Mild Moderate Severe 41.) Nervousness N/A Mild Moderate Severe 42.) Can't gain weight N/A Mild Moderate Severe 43.) Highly emotional N/A Mild Moderate Severe 44.) Increased appetite without weight gain N/A Mild Moderate Severe (B) 45.) Increase in weight N/A Mild Moderate Severe 46.) Decrease in appetite N/A Mild Moderate Severe 47.) Mental sluggishness N/A Mild Moderate Severe 48.) Hair coarse, falls out N/A Mild Moderate Severe (C) 49.) Failing memory N/A Mild Moderate Severe 50.) Decreased sugar tolerance N/A Mild Moderate Severe (D) 51.) Weight gain around hips or waist N/A Mild Moderate Severe 52.) Sex drive reduced or lacking N/A Mild Moderate Severe 53.) Women: menstrual disorders N/A Mild Moderate Severe (E) 54.) Hot flashes N/A Mild Moderate Severe 55.) Hair growth on face or body (female) N/A Mild Moderate Severe (F) 56.) Chronic Fatigue N/A Mild Moderate Severe 57.) Nails weak, ridged N/A Mild Moderate Severe 58.) Tendency to hives N/A Mild Moderate Severe 59.) Perspiration increase N/A Mild Moderate Severe 60.) Crave salt N/A Mild Moderate Severe 61.) Brown spots or bronzing of skin N/A Mild Moderate Severe FEMALE ONLY 62.) Premenstrual tension N/A Mild Moderate Severe 63.) Painful menses N/A Mild Moderate Severe 64.) Depressed feelings before menstruation N/A Mild Moderate Severe 65.) Painful breasts N/A Mild Moderate Severe 66.) Vaginal discharge N/A Mild Moderate Severe MALE ONLY 67.) Prostate trouble N/A Mild Moderate Severe 68.) Urination difficult or dribbling N/A Mild Moderate Severe 69.) Night urination N/A Mild Moderate Severe 70.) Diminished sex drive N/A Mild Moderate Severe 71.) Avoids activity N/A Mild Moderate Severe