Insight into which organs and glands are nutritionally deficient with your function and body.  
There will likely be follow up questions after this survey.

Select the Items that apply, and then let us know how to contact you

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Name
Title
Age/Weight/Height
 

 

Address
 

 

age:

 

E-mail
Phone

  Instructions:

  • Number the lines that apply to you with either a 1,2, or 3.

  • (1) For MILD Symptoms (Occur once or twice a year)

  • (2) For MODERATE Symptoms (Occur several times a year)

  • (3) For SEVERE Symptoms (You are aware of it almost constantly) 

Chief Complaints:

Group 1
     1     2    3
  1 Acid Foods upset
  2 Get Chilled often
  3 "Lump" in throat
  4  Dry mouth- eyes-nose
 5  Pulse speeds up after meal
 6 Keyed up - Fail to Calm
 7 Cuts heal slowly
 8 Gag easily
 9 Unable to relax, startle 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 pain
19 Staring, blinks little
20 Sour stomach frequent

GROUP 2

21 Joint Stiffness after rising
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; feel light headed 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 Get "chilled" frequently
39 Perspire easily
40 Circulation cold

GROUP 3

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 or delayed
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 the afternoons
54 Moods of depression, blues or Melancholy
55 Abnormal craving for sweets or snacks
GROUP 4
56 Hands and feet go to sleep easily, numbness
57 Sigh frequently "air hunger"
58 Aware of breathing heavily
59 High altitude discomfort
60 Open windows in closed rooms
61 Susceptible for colds and fevers
62 Afternoon yawner
63 Get drowsy often
64 Swollen ankles worse at night
65 Muscle cramps. Worse during exercise, get "charlie horses"
66 Shortness of breath on inspiration
67 Dull pain in chest, radiating into left arm
                      worse on exertion
68 Bruise 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 5
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 Use laxatives
89 Stools alternate from soft to Watery
90 History of Gall bladder attacks or Gall stones
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 Crave Sweets
GROUP 6
98 Loss of taste or smell
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 ½ hour after eating; may be up
                        to 2-4 hours
104 Mucus Colitis or irritable bowel syndrome
105 Gas shortly after eating
106 Stomach "bloating after eating"
GROUP 7
                (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 without weight gain
118 Pulse fast at rest
119 Eyelids and face twitch
120 Irritable and restless
121 Can not 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 course falling out
132 Headaches upon rising, wear off during the 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 or waist
145 Sex drive reduced or lacking
146 Tendency to ulcers
147 Increased sugar tolerance
148 Women: menstrual disorders.
149 Young girls, lack of menstrual function
               (E)
50 Dizziness
151 Headaches
152 Hot flashes
153 Increased blood pressure
154 Hair growth on face or body (female)
155 Sugar in urine
156 Masculine tendencies (female)
                  (F)
157 Weakness, Dizziness
158 Chronic fatigue
159 Low blood pressure
160 Nails weak and 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 skin
169 Allergies tendency to asthma
170 Weakness after colds, influenza
171 Exhaustion; muscular and nervous.
172 Respiratory disorders
FEMALE ONLY
173 Very easily fatigued
174 Premenstrual tension
175 Painful menses
176 Depressed feelings before menstruation
177 Menstruation excessive and prolonged
178 Painful breasts
179 Menstruate too frequently
180 Vaginal Discharge
181 Hysterectomy/Ovaries removed
182 Menopausal Hot flashes  
183 Menses scanty or missed
184 Acne, worse at menses
185 Depression of long standing
MALE ONLY
186 Prostate trouble
187 Urination difficult or dribbling
188 Night urination frequent
189 Depression
190 Pain on inside of legs or heels