Symptom Survey Form - Custom Wellness

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Symptom Survey

* Indicates required field

Name *

First

Last

Age *

Date *

Assign a number to the symptoms that you experience in the last 2 weeks using the following scale. (1) for MILD symptoms, (2) for MODERATE symptoms, and (3) for SEVERE symptoms. LEAVE BLANK IF IT DOES NOT APPLY TO YOU!

Group 1

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 meals *

1 2 3

Keyed up - fail to calm *

1 2 3

Cuts heal 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 frequent *

1 2 3

Group 2

Joint stiffness after 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

Always seem hungry; feel 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

Group 3

Eat when nervous *

1 2 3

Excessive appetite *

1 2 3

Hungry between meals *

1 2 3

Irritable before meals *

1 2 3

Get "shaky" if hungry *

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 a few hours, hard to get back to sleep *

1 2 3

Crave candy or coffee in afternoons *

1 2 3

Moods of depressions- "blues" or melancholy *

1 2 3

Abnormal craving for sweets/snacks *

1 2 3

Group 4

Hand 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 room *

1 2 3

Susceptive 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 with exertion *

1 2 3

Bruise easily, "black & 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 breastbone, or feeling of "tightness", worse on exertion *

1 2 3

Group 5

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 movement painful or difficult *

1 2 3

Worries, feels insecure *

1 2 3

Feeling queasy, headaches 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

Craves sweets *

1 2 3

Group 6

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; maybe up to 3-4 hrs *

1 2 3

Mucus colitis or "irritable bowel" *

1 2 3

Gas shortly after eating *

1 2 3

Stomach "bloating" after eating *

1 2 3

Group 7-A

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

Group 7-B

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

Headache upon arising; wear off during day *

1 2 3

Slow pulse, below 65 *

1 2 3

Frequency of urination *

1 2 3

Empaired hearing *

1 2 3

Reduced Initiative *

1 2 3

Group 7-C

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

Group 7-D

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

Group 7-E

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

Group 7-F

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

Females Only

Very easily fatigued *

1 2 3

Premenstrual tension *

1 2 3

Painful menses *

1 2 3

Depressed feeling before menstruation *

1 2 3

Menstruation excessive and prolonged *

1 2 3

Painful breasts *

1 2 3

Menstruate to frequently *

1 2 3

Vaginal discharge *

1 2 3

Hysterectomy/ Ovaries removed *

1 2 3

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

Males 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

Avoid activity *

1 2 3

Leg nervousness at night *

1 2 3

Diminished sex drive *

1 2 3

Please list your 5 main health complaints, in order of importance:

Comment *

Submit

If you are a new client, after filling out the Symptom Survey form, please visit the New Client Orientation page.

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Holland, MI 49423

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