Take a Symptoms Survey
 
 
Name:
Date:
DOB:
Gender

     

Height
Weight:
Blood Pressure (For Doctors Use)
Pulse: 
Sitting:
Standing:
BP Sitting:
PB Lying:
BP Standing:
PH INDICATORS (For Doctors Use)
AM Saliva:
AM Urine:
PM Saliva:
PM Urine:
   
 

Completely black out any of the three circles:

1-mild, 2-moderate, or 3-severe

MILD symptoms (once or twice last 6 month)
MODERATE symptoms (once or twice last month)
SEVERE symptoms (Chronic, once or twice last wk)
Leave circles BLANK if they do not apply to you!
GROUP 1 SYMPATHETIC DOMINANCE
Acid foods upset
Feel Chilled often
“Lump” in throat
Dry mouth-eyes-nose
Pulse speeds after meals
Keyed up; unable to feel calm
Cuts heal slowly
Gag easily
Unable to relax; startles easily
Extremities cold and/or clammy
Strong light irritates
Urine amount reduced
Heart pounds after retiring
“Nervous” stomach
Appetite reduced
Cold sweats often
Body temperature rises easily
Skin sensitive to touch
Staring, blinks little
Frequently have a sour stomach
 
GROUP 2 PARASYMPATHETIC DOMINANCE
Joint stiffness after arising
Muscle-leg-toe cramps at night
“Butterfly” stomach, cramps
Eyes or nose watery
Eyes blink often
Eyelids swollen or puffy
Indigestion soon after meals
Always seem hungry; ‘lightheaded’ often
Food digests rapidly
Vomit frequently
Frequently hoarse
Irregular breathing
Pulse slow or feels “irregular”
Slow gag reflex
Difficulty swallowing
Alternating constipation and diarrhea
“Slow starter”
Not easily chilled
Perspire easily
Poor circulation or sensitive to cold
Subject to colds, asthma, bronchitis
 
GROUP 3 SUGAR HANDLING
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get “shaky” if hungry
Feeling fatigued, eating relieves
“Lightheaded” if meals delayed
Heart palpitates if meals missed or delayed
Afternoon headaches
Upset feeling from excessive eating of sweets
Awaken after a few hours sleep, hard to get back to sleep
Crave candy or coffee in afternoons
Moods of depression, “blues”, or melancholy
Abnormal craving for sweets or snacks
 
GROUP 4 CARDIOVASCULAR
Hands and feet go to sleep easily, numbness
Sigh frequently, “air hunger”
Aware of “breathing heavily”
Discomfort at high altitude
Opens windows in closed room
Susceptible to colds and fevers
Afternoon “yawner”
Get “drowsy” often
Swollen ankles worse at night
Muscle cramps, worse during exercise; “charley-horses”
Shortness of breath on exertion
Dull pain in chest or radiating into left arm, worse on exertion
Bruise easily, “black/blue” spots on arms or legs
Tendency to anemia
Frequently have “nose bleeds”
“Ringing in ears” or noises in head
Tension under the breast-bone, or feeling of “tightness” in the chest, gets worse on exertion
 
GROUP 5 LIVER/BILIARY
Dizziness
Dry skin
Burning feet
Blurred vision
Itching skin and feet
Excessive falling hair
Frequent skin rashes
Bitter or metallic taste in mouth in the mornings
Bowel movements painful or difficult
Feelings of worry, dread, or insecurity
Feeling queasy; headache over eyes
Greasy foods upset
Stools light-colored
Skin peels on foot soles
Pain between shoulder blades
Using laxatives
Stools alternate from soft to watery
History of gallbladder attacks or gall stones
Sneezing attacks
Dreaming, nightmare-type bad dreams
Bad breath (halitosis)
Milk products cause distress
Sensitive to hot weather
Burning or itching anus
Crave sweets
 
GROUP 6 DIGESTION
Loss of taste for meat
Lower bowel gas several hours after eating
Burning stomach sensations, eating relieves
Coated tongue
Pass large amounts of foul smelling gas
Indigestion 1/2 -1 hour after eating; may be up to 3-4 hrs.
Mucus colitis or “irritable bowel”
Gas shortly after eating
Stomach “bloating” after eating
 
GROUP 7A HYPERTHYROID
Insomnia
Nervousness
Can’t gain weight
Intolerance to heat
Highly emotional
Flush easily
Night sweats
Skin is thin and moist
Inward trembling
Heart palpitates
Increased appetite without weight gain
Pulse races when resting
Eyelids and face twitch
Irritable and restless
Can’t work under pressure
 
GROUP 7B HYPOTHYROID
Noticeable weight gain
Decrease in appetite
Easily fatigued
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
Frequent urination
Impaired hearing
Reduced initiative
 
GROUP 7C HYPERPITUITARY
Failing memory
Low blood pressure
Increased sex drive
Headaches, “splitting or rendering” type
Decreased sugar tolerance
 
GROUP 7D HYPOPITUITARY
Abnormal thirst
Bloating of the abdomen
Weight gain around hips or waist
Sex drive reduced or lacking
Tendency towards ulcers and/or colitis
Increased sugar tolerance
(FEMALE) Menstrual disorders
(YOUNG GIRLS) Lack of menstrual function
 
GROUP 7E HYPERADRENAL
Dizziness
Headaches
Hot Flashes
Increased blood pressure
(FEMALE) hair growth on face or body
Sugar in urine (not diabetes )
(FEMALE) Masculine tendencies
 
GROUP 7F HYPOADRENAL
Weakness and/or dizziness
Chronic fatigue
Low blood pressure
Nails weak and/or 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 or influenza
Muscular and nervous exhaustion
Respiratory disorders
 
GROUP 8 FOUNDATION ISSUES
Apprehension
Irritability
Morbid fears
Never seems to get well
Forgetfulness
Indigestion
Poor appetite
Craving for sweets
Muscular soreness
Depression; Feelings of dread
Noise sensitivity
Acoustic hallucinations
Tendency to cry without reason
Hair is coarse and/or thinning
Weakness
Fatigue
Skin sensitive to touch
Tendency toward hives
Nervousness
Headache
Insomnia
Anxiety
Anorexia
Inability to concentrate; confusion
Frequent stuffy nose; sinus infections
Allergy to some foods
Loose joints
 
MALE ONLY
Prostate trouble
Urination difficult or dribbling
Frequent night time urination
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
lack of energy
Migrating aches and pains
Too easily tired
Avoids activity
Leg nervousness at night
Diminished sex drive
 
FEMALE ONLY
Very easy fatigued
Premenstrual tension
Painful menses
Depressed feelings before menstruation
Excessive and prolonged menstruation
Painful breasts
Menstruate too frequently
Vaginal discharge
Hysterectomy / ovaries removed
Menopausal hot flashes
Menses scanty or missed
Acne, worse at menses
Long standing depression