SYSTEMS SURVEY FORM ; - Waéstrs- Patient Doctor Date Birth Date yt ‘Approx Weight Sex: Male [] Female [] Pulse: Recumbent Standing Vegetarian] Gluten-free [] Blood pressure: Recumbent Standing Ragland's Test is Positive [] INSTRUCTIONS: Fill n only the circles which apply to you. © 0.0 MILD symptoms (occurs rarely) (© ©. MODERATE symptoms (occurs several times a month). (0.0 @ SEVERE symptoms (occurs almost constant) 0.0.0 Leave circles BLANK if they don’t apply to you! 0.00 nate stertow tours sep-hrto getbeckt sep 2.9 Cine sant orcitoen sacs 0.00 Moods of depression - "blues" or melancholy S00 aovara cnng or ene snes enour 0.000 Hane ast got sey any, eurness 80 Sgnteqeny arrose 080 seal eshing heir 200 mon ste cacaron 0.89 Operewnfows noses noms 280 Siesta tocas aoe 888 stemoon yma 888 Ger aon oten 888 Stolen anes woe no 988 ede comes, wre dung secs: et chareyhases O80 Shomer ore on oxen 0.0 ulgane ctor ding set am. wo on een “Sask ans "os 889 Tenenyte seme 880 Nowe Bese fear O00 Appetite reduced (0.0.0 Noises in head, or “ringing in ears" 880 Casswes chen 08 Tenean under ie esnborm Stesing tahoe 089 Femremiy ses ‘tte cn seen 280 nesagntte pane 900 Serra nite nooo want 880 soursonsch en 7.000 Ouse 1.23 GROUP 1.0.00 Aci foods upset 2.000 Gotchiled ohen 3.0.00 “Lump"in throat 4.0.00 Dry moutneyes-nose 5 000 Pulse speeds after meal 6 000 Keyed up -fall to calm 7000 Cutheals stony 8 000 Gageasily 9.000 Unable to relax; states easily 10.000 Extremities cals, clammy 11 000 Strong light rates 12.000 Urine amount reduced 3 “ 6 16 7 18 19 20 ©00 Heart pounds ater retiing 0.00 "Nervous" stomach sesseaeassesesse se Group 2 75 0.00 Burning feet 21 0.00 Joint sifness on arising 78 0.00 Blurred vision 22 0.0.0 Muscle-eg-oe cramps at night 77 000 Itching skin and feet 23 0.00 “Buttery” stomach, cramps 78 0.00 Excessive fang hair 24 0.00 Eyes ornose watery 78 0.00 Frequent skin rashes 25 0.00 Eyes blink often 80 0.00 Bitter, metalic taste in mouth in momings 26 0.00 Eyelids swollen, puty 81 0.0.0 Bowel movements painful or difficult 27 0.00 Indigestion soon after meats 82 0.00 Worry, fets insecure 28 0.0.0 Aways seems hungry: feels "ightheaded” often 83 0.00 Feelin queasy; headache over eyes 28 0.00 Digestion rapid 84 0.00 Greasy foods upset 30 0.00 Vomiting frequent 85 0.00 Stools light colored 31 0.00 Hosrseness frequent 88 0.00 Skinpeets on foot soles 32 0.00 Breathing iregular 87 0.00 Pain between shoulder blades 33 0.00 Pulse slow; feels “regular” 88 000 Use laxatives 34 0.00 Gagging refx siow 83 0.00 Stools alternate from soft to watery 35 0.00 Diffcuty swallowing 90 0.00 History of gallbladder attacks or gallstones 36 0.00 Consdpation, diaries alterating 81 0.00 Sneezing attacks 37 000 "Stowstarter 82 0.0.0 Dreaming, nightmare type bad dreams 38 0.00 Get chilled” infrequently 93 0.00 Bad breath (haltosis) 39 0.00 Perspir easily 94 0.00 Mik products cause distress 40 0.0.0 Circulation poor, senstve to cold 95 0.00 Sensiive to hot weather 41 0.0.0 Subject to colds, asthma, bronchitis 98 0.00 Burning or itching anus Grour 3 87 0.00 Crave sweets 42 0.00 Eatwhen nervous GROUP 6 43 0.00 Excessive appetite 98 0.00 Loss of taste for meat 44.0 Hungry between mesie 99 0.0.0 Lower bowel gas several hours after eating 4 0.00 rable before meals 48 0.00 Get shaky" hungry 47 0.00 Fatigue, eating relieves 3 ©.00 Buming stomach sensations eating relieves 00 Coated tongue 0.00 Pass large amounts of foulsmeling 92s 48 0.00 “Lightheaded’ i meals celayen 0.00 Indigestion 1/2 1 hour air eating: may be upto 34 hrs. 49 000 Hear palptetes i meals missed ox delayed ©.0.0 Mucous cols or Trtable bowel” 50. 0.0.0 Afemoon headaches 105 0.0.0 Gos shorty after eating 51 000 Overeating sweets upsets 105 000 Stomach bloating” ater eathg 8888123 107 000 108 000 109 000 110000 111.000 112000 113.000 114.000 118.000 118 000 117000 118000 119000 120000 121.000 12.000 123.000 124000 125.000 128 000 127000 128.000 129000 130000 131000 132000 133 000 134 000 135 000 136. 000 137 000 138. 000 139000 140 000 141 000 142 000 +43 000 144 000 145 000 146 000 147 000 148 000 149 000 150 000 151000 152 000 153 000 154 000 155 000 156.000 187 000 158.000 159 000 160000 161000 162000 163 000 164 000 185 000 185 000 167 000 168 000 162000 GROUP 7A Insomnia Nervousness Cant gain weight Intolerance to heat Highly emotional Fuush easily Night sweats Thin, moist skin Inward trembling Hear palates Increased appette without weight a Pulse fast at est Eyelids and face twitch Intable and restless ‘Carit work under pressure Group 78 Increase in weight Decrease in appetite Fatigue easily Ringing in ears Sleepy during day ‘Sensitive to cold Dry or scaly skin Constipation Menta sluggishness Hair coarse, falls out Headaches upon arising, wear off during day ‘Siow pulse, below 65 Frequency of urination Impaired hearing Reduced iitative GROUP TC Fling memory Low blood pressure Increased sex drive Heedaches, “spiting or rending” type Decreased sugar tolerance GROUP 70 ‘Abnormal thirst Bloating of abdomen Weight gain around hips or waist Sex drive reduced or lacking Tendency to ulcers, coltis Increased sugar tolerance Women: menstrual disorders ‘Young gts: lack of menstrual function GROUP 7E Dizziness Headaches Hot ashes. Increased blood pressure Hair growth on face or body (female) Sugar in urine (not diabetes) Masculine tendencies (female) GROUP 7F Weakness, dizziness Chronic fatigue Low blood pressure Nails weak, ridged Tendency to hives Arthtc tendencies erepiraion increase Bowel disorders oor cieulation ‘Swollen ankles Crave salt Brown spots or bronzing of skin ‘Allegis - tendency to asthma 170 m 172 173 174 178 178 17 178 179 180 tet 182 183 188 185 186 187 188 189 190 491 132 193, 194 195 198 197 198 199 200 201 202 203 204 205 206 207 208 200 210 an 212 213 214 215 216 a7 218 219 220 221 22 223 224 123 000 000 000 000 000 000 000 000 000 000 000 900 000 000 000 000 000 000 000 000 000 000 900 000 000 000 000 000 000 000 200 900 900 000 000 000 000 000 ° 000 00 000 000 ooo 000 000 000 000 000 000 000 900 000 000 000 Weakness after cold, inuenza Exhaustion - muscular and nervous Respiratory disorders GROUP 8 Muscle weakness Lack of Stamina Drowsiness ater esting Muscular soreness Rapid heart beat Hyperstable Feeling ofa band around your head Melancholia (feling of sadness) Swelling of ankles Diminished urination Tendency to consume sweets or carbohydrates Muscle spasms Blurred vision Loss of muscular control Numbness Night sweats Rapid digestion ‘Sensitty to noise Redness of palms of hands and bottom of feet Visible veins on chest and abdomen Hemorrhoids ‘Apprehension (feeting that something bad wil happen) Nervousness causing oss of appetite Nervousness with indigestion Gastiis Forgetfuiness ‘Thinning hie FEMALE ONLY ‘Very easily fatigued Premenstrual tension Painful menses Depressed feelings before menstruation Menstruation excessive and prolonged Painful breasts Menstruate too frequently Vaginal discharge Hysterectomy / ovaries removed ‘Menopausal nt flashes ‘Menses scanty or missed ‘Acne, worse at menses. Depression of lng standing MALE ONLY Prostate trouble Urination dificult or dribbing Night urination frequent Depression Pain on inside of egs or hes Feeling of incomplete bowel evacuation Lack of energy Migrating aches and pains Tire to easiy ‘Avoids activity Leg nervousness at night Diminished sex crive Ut the five main complaints you have in the order of their importance