Birthday:

Sex:

Male Female

Height:		Weight:
PULSE WHEN YOU ARE -
Sitting:		Standing:

BLOOD PRESSURE WHEN YOU ARE -
Sitting:		Laying:		Standing:

pH INDICATORS -
AM Saliva:		AM Urine:
PM Saliva:		PM Urine:

	1  2  3
		MILD symptoms (once or twice last 6 months)
		MODERATE symptoms (once or twice last month)
		SEVERE symptoms (Chronic, once or twice last week)
		Leave circles BLANK if they do not apply to you!

	1  2  3			1  2  3
1.		Acid foods upset	2.		Feel chilled often
3.		“Lump” in throat	4.		Dry mouth-eyes-nose
5.		Pulse speeds after meals	6.		Keyed up; unable to feel calm
7.		Cuts heal slowly	8.		Gag easily
9.		Unable to relax; startles easily	10.		Extremities cold and/or 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.		Body temperature rises easily	18.		Skin sensitive to touch
19.		Staring, blinks little	20.		Frequently has a sour stomach

	1  2  3			1  2  3
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 or puffy
27.		Indigestion soon after meals	28.		Always seems hungry; “lightheaded” often
29.		Food digests rapidly	30.		Vomit frequently
31.		Frequently hoarse	32.		Irregular breathing
33.		Pulse slow or feels “irregular”	34.		Slow gag reflex
35.		Difficulty swallowing	36.		Alternating constipation and diarrhea
37.		“Slow starter”	38.		Not easily chilled
39.		Perspire easily	40.		Poor circulation or sensitive to cold
41.		Subject to colds, asthma, bronchitis

	1  2  3			1  2  3
42.		Eat when nervous	43.		Excessive appetitie
44.		Hungry between meals	45.		Irratable before meals
46.		Get “shaky” if hungry	47.		Feeling fatigued, eating relieves
48.		“Lightheaded” if meals delayed	49.		Heart palpitates if meals missed or delayed
50.		Afternoon headaches	51.		Upset feeling from excessive eating of sweets
52.		Awaken after few hours sleep hard to get back to sleep	53.		Crave candy or coffee in afternoons
54.		Moods of depression “blues” or melancholy	55.		Abnormal craving for sweets or snacks

	1  2  3			1  2  3
56.		Hands and feet go to sleep easily, numbness	57.		Sigh frequently, “air hunger”
58.		Aware of “breathing heavily”	59.		Discomfort at high altitude
60.		Opens windows in closed room	61.		Susceptible to colds and fevers
62.		Afternoon yawner	63.		Get “drowsy” often
64.		Swollen ankles worse at night	65.		Muscle cramps, worse during excercise; “charley-horses”
66.		Shortness of breath on exertion	67.		Dull pain in chest or radiating into left arm, worse on exertion
68.		Bruise easily, ”black/blue” spots on arms or legs	69.		Tendency to anemia
70.		Frequently have “nose bleeds”	71.		“Ringing in ears” or noises in head
72.		Tension under the breast-bone, or feeling of “tightness” in the chest, gets worse on exertion	73.		Dizziness

	1  2  3			1  2  3
74.		Dry skin	75.		Burning feet
76.		Blurred vision	77.		Itching skin and feet
78.		Excessive falling hair	79.		Frequent skin rashes
80.		Bitter or metallic taste in mouth in the mornings	81.		Bowel movements painful or difficult
82.		Feelings of worry, dread, or insecurity	83.		Feeling queasy; headache over eyes
84.		Greasy foods upsets	85.		Stools light-colored
86.		Skin peels on foot soles	87.		Pain between shoulder blades
88.		Using laxatives	89.		Stools alternate from soft to watery
90.		History of gallbladder attacks or gallstones	91.		Sneezing attacks
92.		Dreaming, nightmares/bad dreams	93.		Bad breath (halitosis)
94.		Milk products cause distress	95.		Sensitive to hot weather
96.		Burning or itching anus	97.		Crave sweets

	1  2  3			1  2  3
98.		Loss of taste for meat	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 1/2 - 1 hour after eating; may be up to 3 -4 hrs.
104.		Mucus colitis or “irritable bowel”	105.		Gas shortly after eating
106.		Stomach “bloating” after eating

	1  2  3			1  2  3
107.		Insomnia	108.		Nervousness
109.		Can’t gain weight	110.		Intolerance to heat
111.		Highly emotional	112.		Flush easily
113.		Night sweats	114.		Skin is thin and moist
115.		Inward trembling	116.		Heart palpitates
117.		Increased appetite without weight gain	118.		Pulse races when resting
119.		Eyelids and face twitch	120.		Irritable and restless
121.		Can’t work under pressure

	1  2  3			1  2  3
122.		Noticeable weight gain	123.		Decrease in appetite
124.		Easily fatigued	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, falls out
132.		Headaches upon arising wear off during day	133.		Pulse slow, below 65
134.		Frequent urination	135.		Impaired hearing
136.		Reduced initiative

	1  2  3			1  2  3
137.		Failing memory	138.		Low blood pressure
139.		Increased sex drive	140.		Headaches, “splitting or rending” type
141.		Decreased sugar tolerance

	1  2  3			1  2  3
142.		Abnormal thirst	143.		Bloating of the abdomen
144.		Weight gain around hips or waist	145.		Sex drive reduced or lacking
146.		Tendency toward ulcers and/or colitis	147.		Increased sugar tolerance
148.		(FEMALE) Menstrual disorders	149.		(YOUNG GIRLS) Lack of menstrual function

	1  2  3			1  2  3
150.		Dizziness	151.		Headaches
152.		Hot flashes	153.		Increased blood pressure
154.		(FEMALE) Hair growth on face or body	155.		Sugar in urine (not diabetes)
156.		(FEMALE) Masculine tendencies

	1  2  3			1  2  3
157.		Weakness and/or dizziness	158.		Chronic fatigue
159.		Low blood pressure	160.		Nails weak and/or ridged
161.		Tendency towards hives	162.		Arthritic tendencies
163.		Perspiration increase	164.		Bowel disorders
165.		Poor circulation	166.		Swollen ankles
167.		Crave salt	168.		Brown spots or bronzing of skin
169.		Allergies - tendency to asthma	170.		Weakness after colds or influenza
171.		Muscular and nervous exhaustion	172.		Respiratory disorders

	1  2  3			1  2  3
173.		Apprehension	174.		Irritability
175.		Morbid fears	176.		Never seems to get well
177.		Forgetfulness	178.		Indigestion
179.		Poor appetite	180.		Craving for sweets
181.		Muscular soreness	182.		Depression; feelings of dread
183.		Noise sensitivity	184.		Acoustic hallucinations
185.		Tendency to cry without reason	186.		Hair is course and/or thinning
187.		Weakness	188.		Fatigue
189.		Skin sensitive to touch	190.		Tendency towards hives
191.		Nervousness	192.		Headache
193.		Insomnia	194.		Anxiety
195.		Anorexia	196.		Inability to concentrate; confusion
197.		Frequent stuffy nose; sinus infections	198.		Allergy to some foods
199.		Loose joints

	1  2  3			1  2  3
200.		Very easily fatigued	201.		Premenstrual tension
202.		Painful menses	203.		Depressed feelings before menstruation
204.		Excessive and prolonged menstruation	205.		Painful breasts
206.		Menstruate too frequently	207.		Vaginal discharge
208.		Hysterectomy / ovaries removed	209.		Menopausal hot flashes
210.		Menses scanty or missed	211.		Acne, worse at menses
212.		Long standing depression

	1  2  3			1  2  3
213.		Prostate trouble	214.		Urination difficult or dribbling
215.		Frequent night-time urination	216.		Depression
217.		Pain on inside of legs or heels	218.		Feeling of incomplete bowel evacuation
219.		Lack of energy	220.		Migrating aches and pains
221.		Too easily tired	222.		Avoids activity
223.		Leg nervousness at night	224.		Diminished sex drive

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