Symptom Survey Form
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1
2
3SYMPTOM SURVEY FORM
(Restricted to Professional Use)
PATIENT_____________________________ DOCTOR __________________________ DATE ________________________
AGE_______ PHONE (________)____________________ VEGETARIAN ____ Yes ____ No
INSTRUCTIONS: Circle the number that applies to you. If symptom doesn’t apply, leave blank. Use (1) for MILD symptoms (occurs
once or twice a month), (2) for MODERATE symptoms (occurs several times a month), and (3) for SEVERE symptoms (you are aware of
it almost constantly).
GROUP ONE
- 1 2 3
- 1 2 3
- 1 2 3
1
Acid foods upset
8
Gag easily
15
Appetite reduced
- 1 2 3
- 1 2 3
- 1 2 3
2
Get chilled, often
9
Unable to relax; startles easily
16
Cold sweats often
- 1 2 3
- 1 2 3
- 1 2 3
3
“Lump” in throat
10
Extremities cold, clammy
17
Fever easily raised
- 1 2 3
- 1 2 3
- 1 2 3
4
Dry mouth-eyes-nose
11
Strong light irritates
18
Neuralgia-like pains
- 1 2 3
- 1 2 3
- 1 2 3
5
Pulse speeds after meal
12
Urine amount reduced
19
Staring, blinks little
- 1 2 3
- 1 2 3
- 1 2 3
6
Keyed up – fail to calm
13
Heart pounds after retiring
20
Sour stomach frequent
- 1 2 3
- 1 2 3
7
Cuts heal slowly
14
“Nervous” stomach
GROUP TWO
- 1 2 3
- 1 2 3
- 1 2 3
21
Joint stiffness after arising
29
Digestion rapid
37
“Slow starter”
- 1 2 3
- 1 2 3
- 1 2 3
22
Muscle-leg-toe cramps at night
30
Vomiting frequent
38
Get “chilled” infrequently
- 1 2 3
- 1 2 3
- 1 2 3
23
“Butterfly” stomach, cramps
31
Hoarseness frequent
39
Perspire easily
- 1 2 3
- 1 2 3
- 1 2 3
24
Eyes or nose watery
32
Breathing irregular
40
Circulation poor, sensitive
to cold
- 1 2 3
- 1 2 3
25
Eyes blink often
33
Pulse slow; feels “irregular”
- 1 2 3
41
Subject to colds, asthma,
- 1 2 3
- 1 2 3
26
Eyelids swollen, puffy
34
Gagging reflex slow
bronchitis
- 1 2 3
- 1 2 3
27
Indigestion soon after meals
35
Difficulty swallowing
- 1 2 3
- 1 2 3
28
Always seems hungry; feels
36
Constipation, diarrhea
“lightheaded” often
alternating
GROUP THREE
- 1 2 3
- 1 2 3
- 1 2 3
42
Eat when nervous
49
Heart palpitates if meals
53
Crave candy or coffee in
missed or delayed
afternoons
- 1 2 3
43
Excessive appetite
- 1 2 3
- 1 2 3
50
Afternoon headaches
54
Moods of depression –
- 1 2 3
44
Hungry between meals
“blues” or melancholy
- 1 2 3
51
Overeating sweets upsets
- 1 2 3
45
Irritable before meals
- 1 2 3
55
Abnormal craving for
- 1 2 3
52
Awaken after few hours sleep
- 1 2 3
46
Get “shaky” if hungry
sweets or snacks
– hard to get back to sleep
- 1 2 3
47
Fatigue, eating relieves
- 1 2 3
48
“Lightheaded” if meals delayed
GROUP FOUR
- 1 2 3
- 1 2 3
- 1 2 3
56
Hands and feet go to sleep
63
Get “drowsy” often
68
Bruise easily, “black and
easily, numbness
blue” spots
- 1 2 3
64
Swollen ankles worse at night
- 1 2 3
- 1 2 3
57
Sigh frequently, “air hunger”
69
Tendency to anemia
- 1 2 3
65
Muscle cramps, worse during
- 1 2 3
- 1 2 3
58
Aware of “breathing heavily”
70
“Nose bleeds” frequent
exercise; get “charley horses”
- 1 2 3
- 1 2 3
- 1 2 3
59
High altitude discomfort
66
Shortness of breath on exertion
71
Noises in head, or “ringing
in ears”
- 1 2 3
- 1 2 3
60
Opens windows in closed room
67
Dull pain in chest or radiating
- 1 2 3
into left arm, worse on
72
Tension under the
- 1 2 3
61
Susceptible to colds and fevers
exertion.
breastbone, or feeling of
- 1 2 3
62
Afternoon “yawner”
“tightness” worse on
exertion
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