Order Number Full Name * Your Doctor * Cara Haley Anissa Age * Sex * Male Female Email * List the five main physical complaints you have in order of their importance * Instructions 0 = Not applicable 1 = Mild symptoms (occurs rarely) 2 = MODERATE symptoms (occurs several times a month) 3 = SEVERE symptoms (occurs almost constantly) Group 1 Acid foods upset * 0 1 2 3 Get chilled, often * 0 1 2 3 Lump in throat * 0 1 2 3 Dry mouth-eyes-nose * 0 1 2 3 Pulse speeds after meal * 0 1 2 3 Keyed up - fail to calm * 0 1 2 3 Cuts heal slowly * 0 1 2 3 Gag Easily * 0 1 2 3 Unable to relax, startles easily * 0 1 2 3 Extremities cold, clammy * 0 1 2 3 Strong light irritates * 0 1 2 3 Urine amount reduced * 0 1 2 3 Heart pounds after retiring * 0 1 2 3 Nervous stomach * 0 1 2 3 Appetite reduced * 0 1 2 3 Cold sweats often * 0 1 2 3 Fever easily rasied * 0 1 2 3 Neuralgia-like pains * 0 1 2 3 Staring, blinks little * 0 1 2 3 Sour stomach frequent * 0 1 2 3 Group Two Joint stiffness after arising * 0 1 2 3 Muscle-leg-toe cramps at night * 0 1 2 3 Butterfly stomach cramps * 0 1 2 3 Eyes or nose watery * 0 1 2 3 Eyes blink often * 0 1 2 3 Eyelids swollen, puffy * 0 1 2 3 Indigestion soon after meals * 0 1 2 3 Always seem hungry; feels 'lightheaded' often * 0 1 2 3 Digestion rapid * 0 1 2 3 Vomiting frequent * 0 1 2 3 Hoarseness frequent * 0 1 2 3 Breathing irregular * 0 1 2 3 Pulse slow; feels * 0 1 2 3 Gagging reflex slow * 0 1 2 3 Difficulty swallowing * 0 1 2 3 Constipation, diarrhea alternating * 0 1 2 3 Slow starter * 0 1 2 3 Get chilled infrequently * 0 1 2 3 Perspire easily * 0 1 2 3 Circulation poor, sensitive to cold * 0 1 2 3 Subject to colds, asthma, bronchitis * 0 1 2 3 Group Three Eat when nervous * 0 1 2 3 Excessive appetite * 0 1 2 3 Hungry between meals * 0 1 2 3 Irritable before meals * 0 1 2 3 Get shaky if hungry * 0 1 2 3 Fatigue, eating relieves * 0 1 2 3 Lightheaded if meals delayed * 0 1 2 3 Heart palpitates if meals missed or delayed * 0 1 2 3 Afternoon headaches * 0 1 2 3 Overeating sweets upsets * 0 1 2 3 Awaken after few hours sleep - hard to get back to sleep * 0 1 2 3 Crave candy or coffee in afternoons * 0 1 2 3 Moods of depression - blues or melancholy * 0 1 2 3 Abnormal craving for sweets or snacks * 0 1 2 3 Group Four Hands and feet go to sleep easily, numbness * 0 1 2 3 Sigh frequently, air hunger * 0 1 2 3 Aware of breathing heavily * 0 1 2 3 High altitude discomfort * 0 1 2 3 Opens windows in closed room * 0 1 2 3 Susceptible to colds and fevers * 0 1 2 3 Afternoon yawner * 0 1 2 3 Get drowsy often * 0 1 2 3 Swollen ankles worse at night * 0 1 2 3 Muscle cramps, worse during exercise; get charlie horses * 0 1 2 3 Shortness of breath on exertion * 0 1 2 3 Dull pain in chest or radiating into left arm, worse on exertion * 0 1 2 3 Bruise easily, black and blue spots * 0 1 2 3 Tendency to anemia * 0 1 2 3 Nose bleeds frequent * 0 1 2 3 Noises in head, or ringing in ears * 0 1 2 3 Tensions under breastbone, or feeling of tightness * 0 1 2 3 Group Five Dizziness * 0 1 2 3 Dry Skin * 0 1 2 3 Burning feet * 0 1 2 3 Blurred Vision * 0 1 2 3 Itching skin and feet * 0 1 2 3 Excessive falling hair * 0 1 2 3 Frequent skin rashes * 0 1 2 3 Bitter, metallic taste in mouth in mornings * 0 1 2 3 Bowel movements painful or difficult * 0 1 2 3 Worrier, feels insecure * 0 1 2 3 Feeling queasy; headache over eyes * 0 1 2 3 Greasy foods upset * 0 1 2 3 Stools light-colored * 0 1 2 3 Skin peels on foot soles * 0 1 2 3 Pain between shoulder blades * 0 1 2 3 Use laxatives * 0 1 2 3 Stools alternate from soft to watery * 0 1 2 3 History of gallbladder attacks or gallstones * 0 1 2 3 Sneezing attacks * 0 1 2 3 Dreaming, nightmare type bad dreams * 0 1 2 3 Bad breathe (halitosis) * 0 1 2 3 Milk products cause distress * 0 1 2 3 Sensitive to hot weather * 0 1 2 3 Burning or itching anus * 0 1 2 3 Crave sweets * 0 1 2 3 Group Six Loss of taste for meat * 0 1 2 3 Lower bowel gas several hours after eating * 0 1 2 3 Burning stomach sensations, eating relieves * 0 1 2 3 Coated tongue * 0 1 2 3 Pass large amounts of foul-smelling gas * 0 1 2 3 Indigestion 1/2 - 1 hour after * 0 1 2 3 Mucous colitis or irritable bowel * 0 1 2 3 Gas shortly after eating * 0 1 2 3 Stomach bloat with eating, may be up to 3-4 hours after * 0 1 2 3 Group Seven (A) Insomnia * 0 1 2 3 Nervousness * 0 1 2 3 Can't gain weight * 0 1 2 3 Intolerance to heat * 0 1 2 3 Highly emotional * 0 1 2 3 Flush easily * 0 1 2 3 Night Sweats * 0 1 2 3 Thin, moist skin * 0 1 2 3 Inward trembling * 0 1 2 3 Heart palpitates * 0 1 2 3 Increased appetite without weight gain * 0 1 2 3 Pulse fast at rest * 0 1 2 3 Eyelids and face twitch * 0 1 2 3 Irritable and restless * 0 1 2 3 Can't work under pressure * 0 1 2 3 Group Seven (B) Increase in weight * 0 1 2 3 Decrease in appetite * 0 1 2 3 Fatigue easily * 0 1 2 3 Ringing in ears * 0 1 2 3 Sleepy during day * 0 1 2 3 Sensitive to cold * 0 1 2 3 Dry or scaly skin * 0 1 2 3 Constipation * 0 1 2 3 Mental sluggishness * 0 1 2 3 Hair coarse, falls out * 0 1 2 3 Headaches upon arising wear off during day * 0 1 2 3 Slow pulse, below 65 * 0 1 2 3 Frequency of urination * 0 1 2 3 Impaired hearing * 0 1 2 3 Reduced initiative * 0 1 2 3 Group Seven (C) Failing memory * 0 1 2 3 Low blood pressure * 0 1 2 3 Increased sex drive * 0 1 2 3 Headaches, splitting or rendering type * 0 1 2 3 Decreased sugar tolerance * 0 1 2 3 Group Seven (D) Abnormal thirst * 0 1 2 3 Bloating of abdomen * 0 1 2 3 Weight gain around hips or waist * 0 1 2 3 Sex drive reduced or lacking * 0 1 2 3 Tendency to ulcers, colitis * 0 1 2 3 Increased sugar tolerance * 0 1 2 3 Women: menstrual disorders * 0 1 2 3 Young girls: lack of menstrual function * 0 1 2 3 Group Seven (E) Dizziness * 0 1 2 3 Headaches * 0 1 2 3 Hot flashes * 0 1 2 3 Increased blood pressure * 0 1 2 3 Hair growth on face or body (female) * 0 1 2 3 Sugar in urine (not diabetes) * 0 1 2 3 Masculine tendencies (female) * 0 1 2 3 Group Seven (F) Weakness, dizziness * 0 1 2 3 Chronic fatigue * 0 1 2 3 Low blood pressure * 0 1 2 3 Nails, weak, ridged * 0 1 2 3 Tendency to hives * 0 1 2 3 Arthritic tendencies * 0 1 2 3 Perspiration increase * 0 1 2 3 Bowel disorders * 0 1 2 3 Poor circulation * 0 1 2 3 Swollen ankles * 0 1 2 3 Crave salt * 0 1 2 3 Brown spots or bronzing of skin * 0 1 2 3 Allergies - tendency to asthma * 0 1 2 3 Weakness after colds, influenza * 0 1 2 3 Exhaustion - muscular and nervous * 0 1 2 3 Respiratory disorders * 0 1 2 3 Group Eight Muscle weakness * 0 1 2 3 Lack of stamina * 0 1 2 3 Drowsiness after eating * 0 1 2 3 Muscular soreness * 0 1 2 3 Rapid heart beat * 0 1 2 3 Hyper-irritable * 0 1 2 3 Feeling of a band around your head * 0 1 2 3 Melancholia (feeling of sadness) * 0 1 2 3 Swelling of ankles * 0 1 2 3 Diminished Urination * 0 1 2 3 Tendency to consume sweets or carbs * 0 1 2 3 Muscular Spasms * 0 1 2 3 Blurred vision * 0 1 2 3 Loss of muscular control * 0 1 2 3 Numbness * 0 1 2 3 Night sweats * 0 1 2 3 Rapid digestion * 0 1 2 3 Sensitivity to noise * 0 1 2 3 Redness of palms of hands and bottom of feet * 0 1 2 3 Visible veins on chest and abdomen * 0 1 2 3 Hemorrhoids * 0 1 2 3 Apprehension (feeling that something bad is going to happen) * 0 1 2 3 Nervousness causing loss of appetite * 0 1 2 3 Nervousness with indigestion * 0 1 2 3 Gastritis * 0 1 2 3 Forgetfulness * 0 1 2 3 Thinning hair * 0 1 2 3 FEMALE ONLY Very easily fatigued * 0 1 2 3 Premenstrual tension * 0 1 2 3 Painful menses * 0 1 2 3 Menstruation excessive and prolonged * 0 1 2 3 Painful breasts * 0 1 2 3 Menstruate too frequently * 0 1 2 3 Vaginal Discharge * 0 1 2 3 Hysterectomy / ovaries removed * 0 1 2 3 Menopausal hot flashes * 0 1 2 3 Menses scanty or missed * 0 1 2 3 Acne, worse at menses * 0 1 2 3 Depression of long standing * 0 1 2 3 MALE ONLY Prostate trouble * 0 1 2 3 Urination difficult or dribbling * 0 1 2 3 Night urination frequent * 0 1 2 3 Depression * 0 1 2 3 Pain on inside of legs or heels * 0 1 2 3 Feeling of incomplete bowel evacuation * 0 1 2 3 Lack of energy * 0 1 2 3 Migrating aches and pains * 0 1 2 3 Tired too easily * 0 1 2 3 Avoids activity * 0 1 2 3 Leg nervousness at night * 0 1 2 3 Diminished sex drive * 0 1 2 3
