Birthday:

Sex:

Male Female

Doctor:		Approximate Weight:
Vegetarian:	Yes No	Gallbladder Removed:

Pulse:	Recumbent:		Standing:
Blood Pressure:	Recumbent:		Standing:

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		MILD symptoms (occurs infrequently)
		MODERATE symptoms (occurs frequently)
		SEVERE symptoms (chronic, always present)
		Leave circles BLANK if they do not apply to you!

	1  2  3			1  2  3
1.		Acid foods upset	2.		Get chilled often
3.		“Lump” in throat	4.		Dry mouth-eyes-nose
5.		Pulse speeds after meal	6.		Keyed up - fail to calm
7.		Cut heals slowly	8.		Gag easily
9.		Unable to relax; startles easily	10.		Extremities cold, clammy
11.		Strong light irritates	12.		Urine amount reduced
13.		Heart pounds after retiring	14.		Heart pounds after retiring
15.		Appetite reduced	16.		Cold sweats often
17.		Fever easily raised	18.		Neuralgia-like pains
19.		Staring, blinks little	20.		Sour stomach often

	1  2  3			1  2  3
21.		Joint stiffness on arising	22.		Muscle-leg-toe cramps at night
23.		“Butterfly” stomach, cramps	24.		Eyes or nose water
25.		Eyes blink often	26.		Eyelids swollen, puffy
27.		Indigestion soon after meals	28.		Always seems hungry; feels “lightheaded” often
29.		Digestion rapid	30.		Vomiting frequent
31.		Hoarsenss 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” infrequently
39.		Perspire easily	40.		Circulation poor, sensitive to cold
41.		Subject to colds, asthma, bronchitis

	1  2  3			1  2  3
42.		Eat when nervous	43.		Excessive appetite
44.		Hungry between meals	45.		Irritable before meals
46.		Get “shaky” before meals	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 go back to sleep	53.		Crave candy or coffee in afternoons
54.		Moods of depression - “blues” or melancholy	55.		Abnormal craving for sweets or snacks

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56.		Hands and feet go to sleep easily, numbness	57.		Sigh frequently, “air hunger”
58.		Aware of “breathing heavily”	59.		High altitude discomfort
60.		Opens windows in closed rooms	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: get “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 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

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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 gallbladder attacks or gallstones
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

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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 hours
104.		Mucous colitis or irritable bowel	105.		Gas shortly after eating
106.		Stomach “bloating” after eating

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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’t work under pressure

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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 coarse, falls out
132.		Headaches upon arising, wear off during day	133.		Slow pulse, below 65
134.		Frequency of urination	135.		Impaired hearing
136.		Reduced initiative

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

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142.		Abnormal thirst	143.		Bloating of abdomen
144.		Weight gain around hips or waist	145.		Sex drive reduced or lacking
146.		Tendency to ulcers, colitis	147.		Increased sugar tolerance
148.		Women: menstrual disorders	149.		Young girls: lack of menstrual function

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

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157.		Weakness, dizziness	158.		Chronic fatigue
159.		Low blood pressure	160.		Nails weak, ridged
161.		Tendency to hives	162.		Arthritic tendencies
163.		Perspiration increased	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, influenza
171.		Exhaustion - muscular and nervous	172.		Respiratory disorders

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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 hallucination
185.		Tendency to cry without reason	186.		Hair is coarse and/or thinning
187.		Weakness	188.		Fatigue
189.		Skin sensitive to touch	190.		Tendency toward 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

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200.		Very easily fatigued	201.		Premenstrual tension
202.		Painful menses	203.		Depressed feelings before menstruation
204.		Menstruation excessive and prolonged	205.		Painful breasts
206.		Menstruate too frequently	207.		Vaginal discharge
208.		Hysterectomy / ovaries removed Yes No
209.		Menopausal hot flashes	210.		Menses scanty or missed
211.		Acne, worse at menses	212.		Depression of long standing

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213.		Prostate trouble	214.		Urination difficult or dribbling
215.		Night urination frequent	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.		Tire too easily	222.		Avoids activity
223.		Leg nervousness at night	224.		Diminished sex drive

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