Your Nutrition Guide Symptom Survey
SYMPTOM SURVEY FORM
Tell Us About Yourself
Our goal is to help you improve your health and to do this we need you to tell us about yourself.
First Name Last Name
City State
Sex Date of Birth mm/dd/yyyy
Height in inches Weight in lbs.
Email Blood Pressure
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INSTRUCTIONS:
Select symptoms that apply or leave at default.
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products in our shopping area and have access to even more detailed information as our patient.
NEVER (does not apply) MILD (occurs once or twice a year)
MODERATE (occurs several times a year) SEVERE (you are aware of it almost constantly)

 
GROUP 1
1. Acid foods upset NEVER MILDMODERATESEVERE
2. Get chilled, often NEVER MILDMODERATESEVERE
3. "Lump" in throat NEVER MILDMODERATESEVERE
4. Dry mouth - eyes - nose NEVER MILDMODERATESEVERE
5. Pulse speeds after meals NEVER MILDMODERATESEVERE
6. Keyed up - fail to calm NEVER MILDMODERATESEVERE
7. Cuts heal slowly NEVER MILDMODERATESEVERE
8. Gag easily NEVER MILDMODERATESEVERE
9. Unable to relax; startles easily NEVER MILDMODERATESEVERE
10. Extremities cold, clammy NEVER MILDMODERATESEVERE
11. Strong light irritates NEVER MILDMODERATESEVERE
12. Urine amount reduced NEVER MILDMODERATESEVERE
13. Heart pounds after retiring NEVER MILDMODERATESEVERE
14. "Nervous" stomach NEVER MILDMODERATESEVERE
15. Appetite reduced NEVER MILDMODERATESEVERE
16. Cold sweats often NEVER MILDMODERATESEVERE
17. Fever easily raised NEVER MILDMODERATESEVERE
18. Neuralgia-like pains NEVER MILDMODERATESEVERE
19. Staring, blinks little NEVER MILDMODERATESEVERE
20. Sour stomach frequent NEVER MILDMODERATESEVERE
GROUP 2
21. Joint stiffness after arising NEVER MILDMODERATESEVERE
22. Muscle-leg-toe cramps at night NEVER MILDMODERATESEVERE
23. "Butterfly" stomach, cramps NEVER MILDMODERATESEVERE
24. Eyes or nose watery NEVER MILDMODERATESEVERE
25. Eyes blink often NEVER MILDMODERATESEVERE
26. Eyelids swollen, puffy NEVER MILDMODERATESEVERE
27. Indigestion soon after meals NEVER MILDMODERATESEVERE
28. Always seems hungry; feels "lightheaded" often NEVER MILDMODERATESEVERE
29. Digestion rapid NEVER MILDMODERATESEVERE
30. Vomiting frequent NEVER MILDMODERATESEVERE
31. Hoarseness frequent NEVER MILDMODERATESEVERE
32. Breathing irregular NEVER MILDMODERATESEVERE
33. Pulse slow; feels "Irregular" NEVER MILDMODERATESEVERE
34. Gagging reflex slow NEVER MILDMODERATESEVERE
35. Difficulty swallowing NEVER MILDMODERATESEVERE
36. Constipation, diarrhea alternating NEVER MILDMODERATESEVERE
37. "Slow starter" NEVER MILDMODERATESEVERE
38. Get "chilled" infrequently NEVER MILDMODERATESEVERE
39. Perspire easily NEVER MILDMODERATESEVERE
40. Circulation poor, sensitive to cold NEVER MILDMODERATESEVERE
41. Subject to colds, asthma, bronchitis NEVER MILDMODERATESEVERE
GROUP 3
42. Eat when nervous NEVER MILDMODERATESEVERE
43. Excessive appetite NEVER MILDMODERATESEVERE
44. Hungry between meals NEVER MILDMODERATESEVERE
45. Irritable before meals NEVER MILDMODERATESEVERE
46. Get "shaky" if hungry NEVER MILDMODERATESEVERE
47. Fatigue, eating relieves NEVER MILDMODERATESEVERE
48. "Lightheaded" if meals delayed NEVER MILDMODERATESEVERE
49. Heart palpitates if meals missed or delayed NEVER MILDMODERATESEVERE
50. Afternoon headaches NEVER MILDMODERATESEVERE
51. Overeating sweets upsets NEVER MILDMODERATESEVERE
52. Awaken after few hours sleep - hard to get back to sleep NEVER MILDMODERATESEVERE
53. Crave candy or coffee in afternoons NEVER MILDMODERATESEVERE
54. Moods of depression - "blues" or melancholy NEVER MILDMODERATESEVERE
55. Abnormal craving for sweets or snacks NEVER MILDMODERATESEVERE
GROUP 4
56. Hands and feet go to sleep easily, numbness NEVER MILDMODERATESEVERE
57. Sigh frequently, "air hunger" NEVER MILDMODERATESEVERE
58. Aware of "breathing heavily" NEVER MILDMODERATESEVERE
59. High altitude discomfort NEVER MILDMODERATESEVERE
60. Opens windows in closed room NEVER MILDMODERATESEVERE
61. Susceptible to colds and fevers NEVER MILDMODERATESEVERE
62. Afternoon "yawner" NEVER MILDMODERATESEVERE
63. Get "drowsy" often NEVER MILDMODERATESEVERE
64. Swollen ankles worse at night NEVER MILDMODERATESEVERE
65. Muscle cramps, worse during exercise; get "charley horses" NEVER MILDMODERATESEVERE
66. Shortness of breath on exertion NEVER MILDMODERATESEVERE
67. Dull pain in chest or radiating into left arm, worse on exertion NEVER MILDMODERATESEVERE
68. Bruise easily. "black and blue" spots NEVER MILDMODERATESEVERE
69. Tendency to anemia NEVER MILDMODERATESEVERE
70. "Nose bleeds" frequent NEVER MILDMODERATESEVERE
71. Noises in head or "ringing in ears" NEVER MILDMODERATESEVERE
72. Tension under the breastbone, or feeling of "tightness", worse on exertion NEVER MILDMODERATESEVERE
GROUP 5
73. Dizziness NEVER MILDMODERATESEVERE
74. Dry skin NEVER MILDMODERATESEVERE
75. Burning feet NEVER MILDMODERATESEVERE
76. Blurred vision NEVER MILDMODERATESEVERE
77. Itching skin and feet NEVER MILDMODERATESEVERE
78. Excessive falling hair NEVER MILDMODERATESEVERE
79. Frequent skin rashes NEVER MILDMODERATESEVERE
80. Bitter, metallic taste in mouth in mornings NEVER MILDMODERATESEVERE
81. Bowel movements painful or difficult NEVER MILDMODERATESEVERE
82. Worrier, feels insecure NEVER MILDMODERATESEVERE
83. Feeling queasy; headache over eyes NEVER MILDMODERATESEVERE
84. Greasy foods upset NEVER MILDMODERATESEVERE
85. Stools light-colored NEVER MILDMODERATESEVERE
86. Skin peels on foot soles NEVER MILDMODERATESEVERE
87. Pain between shoulder blades NEVER MILDMODERATESEVERE
88. Use laxatives NEVER MILDMODERATESEVERE
89. Stools alternate from soft to watery NEVER MILDMODERATESEVERE
90. History of gallbladder attacks or gallstones NEVER MILDMODERATESEVERE
91. Sneezing attacks NEVER MILDMODERATESEVERE
92. Dreaming, nightmare type bad dreams NEVER MILDMODERATESEVERE
93. Bad breath (halitosis) NEVER MILDMODERATESEVERE
94. Milk products cause distress NEVER MILDMODERATESEVERE
95. Sensitive to hot weather NEVER MILDMODERATESEVERE
96. Burning or itching anus NEVER MILDMODERATESEVERE
97. Crave sweets NEVER MILDMODERATESEVERE
GROUP 6
98. Loss of taste for meat NEVER MILDMODERATESEVERE
99. Lower bowel gas several hours after eating NEVER MILDMODERATESEVERE
100. Burning stomach sensations, eating relieves NEVER MILDMODERATESEVERE
101. Coated tongue NEVER MILDMODERATESEVERE
102. Pass large amounts of foul smelling gas NEVER MILDMODERATESEVERE
103. Indigestion 1/2 - 1 hour after eating; may be up to 3 hrs. NEVER MILDMODERATESEVERE
104. Mucus colitis or "irritable bowel" NEVER MILDMODERATESEVERE
105. Gas shortly after eating NEVER MILDMODERATESEVERE
106. Stomach "bloating" after eating NEVER MILDMODERATESEVERE
GROUP 7A
107. Insomnia NEVER MILDMODERATESEVERE
108. Nervousness NEVER MILDMODERATESEVERE
109. Can't gain weight NEVER MILDMODERATESEVERE
110. Intolerance to heat NEVER MILDMODERATESEVERE
111. Highly emotional NEVER MILDMODERATESEVERE
112. Flush easily NEVER MILDMODERATESEVERE
113. Night sweats NEVER MILDMODERATESEVERE
114. Thin, moist skin NEVER MILDMODERATESEVERE
115. Inward trembling NEVER MILDMODERATESEVERE
116. Heart palpitates NEVER MILDMODERATESEVERE
117. Increased appetite without weight gain NEVER MILDMODERATESEVERE
118. Pulse fast at rest NEVER MILDMODERATESEVERE
119. Eyelids and face twitch NEVER MILDMODERATESEVERE
120. Irritable and restless NEVER MILDMODERATESEVERE
121. Can't work under pressure NEVER MILDMODERATESEVERE
GROUP 7B
122. Increase in weight NEVER MILDMODERATESEVERE
123. Decrease in appetite NEVER MILDMODERATESEVERE
124. Fatigue easily NEVER MILDMODERATESEVERE
125. Ringing in ears NEVER MILDMODERATESEVERE
126. Sleepy during day NEVER MILDMODERATESEVERE
127. Sensitive to cold NEVER MILDMODERATESEVERE
128. Dry or scaly skin NEVER MILDMODERATESEVERE
129. Constipation NEVER MILDMODERATESEVERE
130. Mental sluggishness NEVER MILDMODERATESEVERE
131. Hair coarse, tails out NEVER MILDMODERATESEVERE
132. Headaches upon arising wear off during day NEVER MILDMODERATESEVERE
133. Slow pulse, below 65 NEVER MILDMODERATESEVERE
134. Frequency of urination NEVER MILDMODERATESEVERE
135. Impaired hearing NEVER MILDMODERATESEVERE
136. Reduced initiative NEVER MILDMODERATESEVERE
GROUP 7C
137. Failing memory NEVER MILDMODERATESEVERE
138. Low blood pressure NEVER MILDMODERATESEVERE
139. Increased sex drive NEVER MILDMODERATESEVERE
140. Headaches, "splitting or rendering" type NEVER MILDMODERATESEVERE
141. Decreased sugar tolerance NEVER MILDMODERATESEVERE
GROUP 7D
142. Abnormal thirst NEVER MILDMODERATESEVERE
143. Bloating of abdomen NEVER MILDMODERATESEVERE
144. Weight gain around hips or waist NEVER MILDMODERATESEVERE
145. Sex drive reduced or lacking NEVER MILDMODERATESEVERE
146. Tendency to ulcers, colitis NEVER MILDMODERATESEVERE
147. Increased sugar tolerance NEVER MILDMODERATESEVERE
148. Women: menstrual disorders NEVER MILDMODERATESEVERE
149. Young girls: lack of menstrual function NEVER MILDMODERATESEVERE
GROUP 7E
150. Dizziness NEVER MILDMODERATESEVERE
151. Headaches NEVER MILDMODERATESEVERE
152. Hot flashes NEVER MILDMODERATESEVERE
153. Increased blood pressure NEVER MILDMODERATESEVERE
154. Hair growth on face or body (female) NEVER MILDMODERATESEVERE
155. Sugar in urine (not diabetes) NEVER MILDMODERATESEVERE
156. Masculine tendencies (female) NEVER MILDMODERATESEVERE
GROUP 7F
157. Weakness, dizziness NEVER MILDMODERATESEVERE
158. Chronic fatigue NEVER MILDMODERATESEVERE
159. Low blood pressure NEVER MILDMODERATESEVERE
160. Nails weak, ridged NEVER MILDMODERATESEVERE
161. Tendency to hives NEVER MILDMODERATESEVERE
162. Arthritic tendencies NEVER MILDMODERATESEVERE
163. Perspiration increase NEVER MILDMODERATESEVERE
164. Bowel disorders NEVER MILDMODERATESEVERE
165. Poor circulation NEVER MILDMODERATESEVERE
166. Swollen ankles NEVER MILDMODERATESEVERE
167. Crave salt NEVER MILDMODERATESEVERE
168. Brown spots or bronzing of skin NEVER MILDMODERATESEVERE
169. Allergies - tendency to asthma NEVER MILDMODERATESEVERE
170. Weakness after colds, influenza NEVER MILDMODERATESEVERE
171. Exhaustion - muscular and nervous NEVER MILDMODERATESEVERE
172. Respiratory disorders NEVER MILDMODERATESEVERE
FEMALE ONLY
173. Very easily fatigued NEVER MILDMODERATESEVERE
174. Premenstrual tension NEVER MILDMODERATESEVERE
175. Painful menses NEVER MILDMODERATESEVERE
176. Depressed feelings before menstruation NEVER MILDMODERATESEVERE
177. Menstruation excessive and prolonged NEVER MILDMODERATESEVERE
178. Painful breasts NEVER MILDMODERATESEVERE
179. Menstruate too frequently NEVER MILDMODERATESEVERE
180. Vaginal discharge NEVER MILDMODERATESEVERE
181. Hysterectomy/ovaries removed NEVER MILDMODERATESEVERE
182. Menopausal hot flashes NEVER MILDMODERATESEVERE
183. Menses scanty or missed NEVER MILDMODERATESEVERE
184. Acne, worse at menses NEVER MILDMODERATESEVERE
185. Depression of long standing NEVER MILDMODERATESEVERE
MALE ONLY
186. Prostate trouble NEVER MILDMODERATESEVERE
187. Urination difficult or dribbling NEVER MILDMODERATESEVERE
188. Night urination frequent NEVER MILDMODERATESEVERE
189. Depression NEVER MILDMODERATESEVERE
190. Pain on inside of legs or heels NEVER MILDMODERATESEVERE
191. Feeling of incomplete bowel evacuation NEVER MILDMODERATESEVERE
192. Lack of energy NEVER MILDMODERATESEVERE
193. Migrating aches and pains NEVER MILDMODERATESEVERE
194. Tire too easily NEVER MILDMODERATESEVERE
195. Avoids activity NEVER MILDMODERATESEVERE
196. Leg nervousness at night NEVER MILDMODERATESEVERE
197. Diminished sex drive NEVER MILDMODERATESEVERE
GROUP 8
198. Apprehension NEVER MILDMODERATESEVERE
199. Irritability NEVER MILDMODERATESEVERE
200. Morbid Fears NEVER MILDMODERATESEVERE
201. Never seems to get well NEVER MILDMODERATESEVERE
202. Forgetfulness NEVER MILDMODERATESEVERE
203. Indigestion NEVER MILDMODERATESEVERE
204. Poor appetite NEVER MILDMODERATESEVERE
205. Craving for sweets NEVER MILDMODERATESEVERE
206. Muscular soreness NEVER MILDMODERATESEVERE
207. Depression; feelings of dread NEVER MILDMODERATESEVERE
208. Noise sensitivity NEVER MILDMODERATESEVERE
209. Acoustic hallucinations NEVER MILDMODERATESEVERE
210. Tendency to cry without reason NEVER MILDMODERATESEVERE
211. Hair is coarse and/or thinning NEVER MILDMODERATESEVERE
212. Weakness NEVER MILDMODERATESEVERE
213. Fatigue NEVER MILDMODERATESEVERE
214. Skin sensitive to touch NEVER MILDMODERATESEVERE
215. Tendency towards hives NEVER MILDMODERATESEVERE
216. Nervousness NEVER MILDMODERATESEVERE
217. Headache NEVER MILDMODERATESEVERE
218. Insomnia NEVER MILDMODERATESEVERE
219. Anxiety NEVER MILDMODERATESEVERE
220. Anorexia NEVER MILDMODERATESEVERE
221. Inability to concentrate; confusion NEVER MILDMODERATESEVERE
222. Frequent stuffy nose; sinus infections NEVER MILDMODERATESEVERE
223. Allergy to some foods NEVER MILDMODERATESEVERE
224. Loose joints NEVER MILDMODERATESEVERE

COMMENTS
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