Symptom Survey Form Page 3
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3SYMPTOM SURVEY FORM – Page 3
GROUP EIGHT
FEMALE ONLY
MALE ONLY
- 1 2 3
213
Prostate trouble
- 1 2 3
- 1 2 3
173
Apprehension
200
Very easily fatigued
- 1 2 3
214
Urination difficult or
- 1 2 3
- 1 2 3
174
Irritability
201
Premenstrual tension
dribbling
- 1 2 3
- 1 2 3
- 1 2 3
175
Morbid fears
202
Painful menses
215
Night urination frequent
- 1 2 3
- 1 2 3
- 1 2 3
176
Never seems to get well
203
Depressed feelings
216
Depression
- 1 2 3
- 1 2 3
- 1 2 3
177
Forgetfulness
204
Menstruation excessive
217
Pain on inside of legs or
and prolonged
heels
- 1 2 3
178
Indigestion
- 1 2 3
- 1 2 3
205
Painful breasts
218
Feeling of incomplete
- 1 2 3
179
Poor appetite
bowel evacuation
- 1 2 3
206
Menstruate too frequently
- 1 2 3
180
Craving for sweets
- 1 2 3
219
Lack of energy
- 1 2 3
207
Vaginal discharge
- 1 2 3
181
Muscular soreness
- 1 2 3
220
Migrating aches and
- 1 2 3
208
Hysterectomy/ovaries
- 1 2 3
182
Depression; feelings of dread
pains
removed
- 1 2 3
183
Noise sensitivity
- 1 2 3
221
Tire too easily
- 1 2 3
209
Menopausal hot flashes
- 1 2 3
184
Acoustic hallucinations
- 1 2 3
222
Avoids activity
- 1 2 3
210
Menses scanty or
- 1 2 3
185
Tendency to cry without reason
- 1 2 3
223
Leg nervousness at night
issed
m
- 1 2 3
186
Hair is coarse and/or thinning
- 1 2 3
- 1 2 3
224
Diminished sex drive
211
Acne, worse at menses
- 1 2 3
187
Weakness
- 1 2 3
212
Depression of long
- 1 2 3
188
Fatigue
standing
- 1 2 3
189
Skin sensitive to touch
IMPORTANT
- 1 2 3
190
Tendency toward hives
- 1 2 3
191
Nervousness
TO THE PATIENT: Please list below the five main physical complaints you
have in order of their importance:
- 1 2 3
192
Headache
- 1 2 3
193
Insomnia
1.
- 1 2 3
194
Anxiety
2.
- 1 2 3
195
Anorexia
3.
- 1 2 3
196
Inability to concentrate; confusion
- 1 2 3
197
Frequent stuffy nose; sinus infections
4.
- 1 2 3
198
Allergy to some foods
5.
- 1 2 3
199
Loose joints
(TO BE COMPLETED BY DOCTOR)
Postural Blood Pressure: Recumbent
Standing
Pulse
Hema-Combistix Urine readings: pH
Albumin per cent
Glucose per cent
Occult Blood
pH of Saliva
pH of Stool specimen
Weight
Hemoglobin
Blood Clotting Time
BARNES THYROID TEST
You can do the following test at home to see if you may have a
This test was developed by Dr. Broda Barnes, M.D. and is a measurement of the
functional low thyroid. Use an oral thermometer or a digital one.
underarm temperature to determine hypo and hyperthyroid states. The test is conducted
When you use a digital one, place the probe under your arm for 5
by the patient in the a.m. before leaving bed - with the temperature being taken for 10
minutes then turn your machine on; continue on for an additional 5
minutes. The test is invalidated if the patient expends any energy prior to taking the test
minutes. When using a regular one, shake down the night before.
- getting up for any reason, shaking down the thermometer, etc. It is important that the
test be conducted for exactly 10 minutes, making the prior positioning of both the
Date: _________________Temperature: ________________
thermometer and a clock important.
PRE-MENSES FEMALES AND MENOPAUSAL FEMALES
Date: _________________Temperature: ________________
Any two days during the month
Date: _________________Temperature: ________________
FEMALES HAVING MENSTRUAL CYCLES
Date: _________________Temperature: ________________
The 2nd and 3rd day of flow OR any 5 days in a row.
Date: _________________Temperature: ________________
MALES
Any 2 days during the month.
Date: _________________Temperature: ________________
Date: _________________Temperature: ________________
BP SIT_______________________
BP STAND_______________________
PULSE SIT___________________
PULSE STAND___________________
SALIVA PH___________________
BLOOD TYPE____________________
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