SymptomSurvey

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1. Acid foods upset

2. Get 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. Gag 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

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; "lightheaded"

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 alternates

37. "Slow starter"

38. Get "chilled" infrequently

39. Perspire easily

40. Circulation poor, sensitive to cold

41. Subject to colds, asthma, bronchitis

42. Eat when nervous

43. Excessive appetite

44. Hungry between meals

45. Irritable before meals

46. Get "shaky" if hungry

47. Fatigue, eating relieves

48. "Lightheaded" if meals delayed

49. Heart palpitates if meals missed

50. Afternoon headaches

51. Overeating sweets upsets

52. Awaken after few hours sleep -

hard to get back to sleep

53. Crave candy or coffee in afternoons

54. Moods of depression - "the blues"

55. Abnormal craving for sweets or snacks

56. Hands/feet go to sleep, numbness

57. Sigh 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. Get "drowsy" often

64. Swollen ankles worse at night

65. Muscle cramps, worse during

exercise; get "charley horses"

66. Shortness of breath on exertion

67. Dull pain in chest or radiating

into left arm, worse on exertion

68. Bruise easily, "black & blue" marks

69. Tendency to anemia

70. "Nose bleeds" frequent

71. Noises in head or "ringing in ears"

72. Tension under the breastbone or feel-

ing of "tightness", worse on exertion

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 morning

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. Use laxatives

89. Stools alternate, soft to watery

90. History of gallbladder attacks or

gallstones

91. Sneezing attacks

92. Dreaming, nightmares/bad dreams

93. Bad breath (halitosis)

94. Milk products cause distress

95. Sensitive to hot weather

96. Burning or itching anus

97. Crave sweets

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 hr after eating;

may be up to 3-4 hrs

104. Musous colitis or "irritible bowel"

105. Gas shortly after eating

106. Stomach "bloating" after eating

(A)

107. Insomnia

108. Nervousness

109. Can't gain weight

110. Intolerance to heat

111. Highly emotional

112. Flush easily

113. Night sweats

114. Thin, moist skin

115. Inward trembling

116. Heart palpitates

117. Increased appetite wo/ weight gain

118. Pulse fast at rest

119. Eyelids and face twitch

120. Irritable and restless

121. Can't work under pressure

(B)

122. Increase in weight

123. Decrease in appetite

124. Fatigue 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, wear off

during day

133. Slow pulse, below 65

134. Frequency of urination

135. Impaired hearing

136. Reduced initiative

(C)

137. Failing memory

138. Low blood pressure

139. Increased sex drive

140. Headaches, "splitting or

rendering" type

141. Decreased sugar tolerance

(D)

142. Abnormal thirst

143. Bloating of abdomen

144. Weight gain around hips/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 menses

(E)

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)

(F)

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. Crave salt

168. Brown spots or bronzing of skin

169. Allergies - tendency to asthma

170. Weakness after colds, influenza

171. Exhaustion (muscular & nervous)

172. Respiratory disorders

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. Depressed feelings before

menstruation

204. Menstruation excessive and

prolonged

205. Painful breasts

206. Menstruate too frequently

207. Vaginal discharge

208. Hysterectomy/ovaries removed

209. Menopausal hot flashes

210. Menses scanty or missed

211. Acne, worse at menses

212. Depression of long standing

213. Prostate trouble

214. Urination difficult or dribbling

215. Night urination frequent

216. Depression

217. Pain on inside of legs or heels

218. Feeling of incomplete bowel

evacuation

219. Lack of energy

220. Migrating aches and pains

221. Tire too easily

222. Avoids activity

223. Leg nervousness at night

224. Diminished sex drive

Please list the 5 main physical complaints you have in order of their importance: