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
