Symptom Survey Form Page 2
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3SYMPTOM SURVEY FORM – Page 2
GROUP FIVE
- 1 2 3
- 1 2 3
- 1 2 3
73
Dizziness
82
Worrier, feels insecure
90
History of gallbladder
attacks or gallstones
- 1 2 3
- 1 2 3
74
Dry Skin
83
Feeling queasy; headache over
- 1 2 3
91
Sneezing attacks
eyes
- 1 2 3
75
Burning feet
- 1 2 3
- 1 2 3
84
Greasy foods upset
92
Dreaming, nightmare type
- 1 2 3
76
Blurred vision
bad dreams
- 1 2 3
85
Stools light-colored
- 1 2 3
77
Itching skin and feet
- 1 2 3
93
Bad breath (halitosis)
- 1 2 3
86
Skin peels on foot soles
- 1 2 3
78
Excessive falling hair
- 1 2 3
94
Milk products cause distress
- 1 2 3
87
Pain between shoulder blades
- 1 2 3
79
Frequent skin rashes
- 1 2 3
95
Sensitive to hot weather
- 1 2 3
88
Use laxatives
- 1 2 3
80
Bitter, metallic taste in mouth in
- 1 2 3
96
Burning or itching anus
- 1 2 3
89
Stools alternate from soft to
mornings
- 1 2 3
97
Crave sweets
watery
- 1 2 3
81
Bowel movements painful or
difficult
GROUP SIX
- 1 2 3
- 1 2 3
- 1 2 3
98
Loss of taste for meat
101
Coated tongue
104
Mucous colitis or “irritable
bowel”
- 1 2 3
- 1 2 3
99
Lower bowel gas several hours
102
Pass large amounts of foul-
- 1 2 3
105
Gas shortly after eating
after eating
smelling gas
- 1 2 3
- 1 2 3
- 1 2 3
100
Burning stomach sensations,
103
Indigestion ½ - 1 hour after
106
Stomach “bloating” after
eating relieves
eating; may be up to 3 – 4
eating
hrs.
GROUP SEVEN
(A)
(E)
- 1 2 3
- 1 2 3
107
Insomnia
150
Dizziness
- 1 2 3
- 1 2 3
108
Nervousness
151
Headaches
- 1 2 3
- 1 2 3
109
Can’t gain weight
152
Hot flashes
- 1 2 3
- 1 2 3
110
Intolerance to heat
153
Increased blood pressure
- 1 2 3
- 1 2 3
111
Highly emotional
154
Hair growth on face or
body (female)
- 1 2 3
112
Flush easily
- 1 2 3
155
Sugar in urine (not
- 1 2 3
113
Night sweats
(C)
diabetes)
- 1 2 3
114
Thin, moist skin
- 1 2 3
137
Failing memory
- 1 2 3
156
Masculine tendencies
- 1 2 3
115
Inward trembling
- 1 2 3
(female)
138
Low blood pressure
- 1 2 3
116
Heart palpitates
- 1 2 3
139
Increased sex drive
(F)
- 1 2 3
117
Increased appetite without
- 1 2 3
140
Headaches, “splitting or
- 1 2 3
157
Weakness, dizziness
weight gain
rending” type
- 1 2 3
- 1 2 3
118
Pulse fast at rest
158
Chronic fatigue
- 1 2 3
141
Decreased sugar tolerance
- 1 2 3
- 1 2 3
119
Eyelids and face twitch
159
Low blood pressure
- 1 2 3
- 1 2 3
120
Irritable and restless
160
Nails weak, ridged
(D)
- 1 2 3
- 1 2 3
121
Can’t work under pressure
161
Tendency to hives
- 1 2 3
142
Abnormal thirst
- 1 2 3
162
Arthritic tendencies
- 1 2 3
(B)
143
Bloating of abdomen
- 1 2 3
163
Perspiration increase
- 1 2 3
- 1 2 3
122
Increase in weight
144
Weight gain around hips or
- 1 2 3
164
Bowel disorders
- 1 2 3
waist
123
Decrease in appetite
- 1 2 3
165
Poor circulation
- 1 2 3
- 1 2 3
145
Sex drive reduced or lacking
124
Fatigue easily
- 1 2 3
166
Swollen ankles
- 1 2 3
146
Tendency to ulcers, colitis
- 1 2 3
125
Ringing in ears
- 1 2 3
167
Crave salt
- 1 2 3
- 1 2 3
147
Increased sugar tolerance
126
Sleepy during day
- 1 2 3
168
Brown spots or bronzing of
- 1 2 3
- 1 2 3
148
Women: menstrual disorders
127
Sensitive to cold
skin
- 1 2 3
149
Young girls: lack of menstrual
- 1 2 3
128
Dry or scaly skin
- 1 2 3
169
Allergies – tendency to
function
- 1 2 3
129
Constipation
asthma
- 1 2 3
- 1 2 3
130
Mental sluggishness
170
Weakness after colds,
influenza
- 1 2 3
131
Hair coarse, falls out
- 1 2 3
171
Exhaustion – muscular and
- 1 2 3
132
Headaches upon arising wear
nervous
off during day
- 1 2 3
172
Respiratory disorders
- 1 2 3
133
Slow pulse, below 65
- 1 2 3
134
Frequency of urination
- 1 2 3
135
Impaired hearing
- 1 2 3
136
Reduced initiative
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