Systems Survey

Systems Survey

Instructions

Select the number that applies to you. If a symptom does not apply, select N/A for that symptom. The Next button to proceed to the following section will appear when each symptom has been addressed.

N/A - Not Applicable
1 - MILD Symptom (occurs rarely)
2 - MODERATE Symptom (occurs several times a month)
3 - SEVERE Symptom (occurs almost constantly)

Group 1

Dryness*

Get chilled often

"Lump" in throat​​​​​​​

Dry mouth, eyes, nose​​​​​​​

Pulse speeds after meal​​​​​​​

Keyed up, fail to calm​​​​​​​

Gag occasionally​​​​​​​

Unable to relax, startle easily​​​​​​​

Extremities cold, clammy​​​​​​​

Strong light irritates​​​​​​​

Occasionally weak urine flow​​​​​​​

Heart pounds after retiring​​​​​​​

"Nervous" stomach​​​​​​​

Appetite reduced occasionally​​​​​​​

Cold sweats often​​​​​​​​​​​​​​

Get heated easily​​​​​​​

Nerve discomfort​​​​​​​

Staring, blink little​​​​​​​

Sour stomach frequent​​​​​​​

Group 2

Joint stiffness after arising​​​​​​​

Muscle, leg, toe cramps at night​​​​​​​

"Butterfly" stomach, cramps​​​​​​​

Eyes or nose watery​​​​​​​

Eyes blink often​​​​​​​

Eyelids swollen, puffy​​​​​​​

Indigestion soon after meals​​​​​​​

Always seem hungry, feel "lightheaded" often​​​​​​​

Digestion rapid​​​​​​​

Vomit occasionally​​​​​​​

Hoarseness frequent​​​​​​​

Uneven breathing​​​​​​​

Pulse slow​​​​​​​

Gagging reflex slow​​​​​​​

Difficulty swallowing​​​​​​​

Temporary constipation or diarrhea​​​​​​​

"Slow starter"​​​​​​​

Get "chilled"​​​​​​​​​​​​​​

Perspire easily​​​​​​​

Sensitive to cold​​​​​​​

Upper respiratory challenges​​​​​​​

Group 3

Eat when nervous

Excessive appetite​​​​​​​

Hungry between meals​​​​​​​

Irritable before meals​​​​​​​

Get "shaky" if hungry​​​​​​​

Eyelids swollen, puffy​​​​​​​

Fatigue, eating relieves​​​​​​​

"Lightheaded" if meals delayed​​​​​​​

Heart palpitates if meals are missed or delayed

Fatigue in afternoon​​​​​​​

Overeating sweets upsets​​​​​​​

Awaken after few hours sleep, hard to get back to sleep​​​​​​​

Crave candy or coffee in afternoon​​​​​​​

Moods of "blues" or melancholy​​​​​​​

Craving for sweets or snacks​​​​​​​

Get "chilled"​​​​​​​​​​​​​​

Group 4

Hands and feet go to sleep easily, numbness

Sigh frequently, "air hunger"​​​​​​​

Aware of "breathing heavily"​​​​​​​

High-altitude discomfort​​​​​​​

Open windows in closed room​​​​​​​

Immune system challenges​​​​​​​

Afternoon "yawner"​​​​​​​

Get "drowsy" often​​​​​​​

Swollen ankles worse at night

Muscle cramps, worse during exercise; get "charley horse"​​​​​​​

Difficulty catching breath, especially during exercise​​​​​​​

Tightness or pressure in chest, worse on exertion​​​​​​​

Skin discolors easily after impact​​​​​​​

Tendency to anemia​​​​​​​

Noises in head or "ringing in ears"​​​​​​​

Fatigue upon exertion​​​​​​​

Group 5

Dizziness

Dry skin​​​​​​​​​​​​​

Burning feet​​​​​​​

Blurred vision​​​​​​​

Itching skin and feet​​​​​​​

Hair loss​​​​​​​

Occasional skin rashes​​​​​​​

Bitter, metallic taste in mouth in morning​​​​​​​

Occasional constipation​​​​​​​

Worrier, feels insecure​​​​​​​

Nausea occasionally after eating​​​​​​​

Greasy foods upset​​​​​​​

Stools light-colored​​​​​​​

Skin peels on foot soles​​​​​​​

Discomfort between shoulder blades​​​​​​​

Occasional laxative use​​​​​​​

Stools alternate from soft to watery​​​​​​​

Sneezing attacks​​​​​​​

Dreaming, nightmare-type bad dreams​​​​​​​

Bad breath (halitosis)​​​​​​​

Milk products cause upset​​​​​​​

Sensitive to hot weather​​​​​​​

Burning or itching anus​​​​​​​

Crave sweets

Group 6

Loss of taste for meat

Lower bowel gas several hours after eating​​​​​​​

Burning stomach sensations, eating relieves

Coated tongue​​​​​​​

Pass large amounts of foul-smelling gas​​​​​​​

Indigestion 1/2-1 hour after eating; may be up to 3-4 hours after​​​​​​​

Watery or loose stool

Gas shortly after eating​​​​​​​

Stomach "bloating"​​​​​​​

Group 7A

Difficulty sleeping​​​​​​​

On edge​​​​​​​

Can't gain weight​​​​​​​

Intolerance to heat​​​​​​​

Highly emotional​​​​​​​

Flush easily​​​​​​​

Night sweats​​​​​​​

Thin, moist skin​​​​​​​

Inward trembling​​​​​​​

Heart races​​​​​​​

Increased appetite without weight gain​​​​​​​

Pulse fast at rest​​​​​​​

Eyelids and face twitch​​​​​​​

Irritable and restless​​​​​​​

Can't work under pressure​​​​​​​

Group 7B

Increase in weight

Decrease in appetite​​​​​​​

Fatigue easily​​​​​​​

Ringing in ears​​​​​​​

Sleepy during day​​​​​​​

Sensitive to cold​​​​​​​

Dry or scaly skin​​​​​​​

Temporary constipation

Mental sluggishness​​​​​​​

Hair coarse, falls out​​​​​​​

Tension in head upon arising wears off during day​​​​​​​

Slow pulse below 65​​​​​​​

Changing urinary function​​​​​​​

Sounds appear diminished​​​​​​​

Reduced initiative

Group 7C

Failing memory with age​​​​​​​

Increased sex drive

Episodes of tension in head​​​​​​​

Decreased sugar tolerance​​​​​​​

Group 7D

Abnormal thirst​​​​​​​

Bloating of abdomen​​​​​​​

Weight gain around hips or waist​​​​​​​

Sex drive reduced or lacking​​​​​​​

Tendency for stomach issues​​​​​​​

Immune system challenges​​​​​​​

Menstrual disorders​​​​​​​

Group 7E

Dizziness​​​​​​​

Headaches​​​​​​​

Hot flashes​​​​​​​

Hair growth on face or body (female)​​​​​​​

Sugar in urine (not diabetes)​​​​​​​

Masculine tendencies (female)​​​​​​​

Group 7F

Weakness, dizziness​​​​​​​

Tired throughout day​​​​​​​

Nails weak, ridged​​​​​​​

Sensitive skin​​​​​​​

Stiff joints​​​​​​​

Perspiration increase​​​​​​​

Bowel discomfort​​​​​​​

Poor circulation​​​​​​​

Swollen ankles

Crave salt

Areas of skin darkening​​​​​​​

Upper respiratory sensitivity

Tiredness​​​​​​​

Breathing challenges​​​​​​​

Group 8

Muscle weakness​​​​​​​​​​​​​​

Lack of stamina​​​​​​​

Drowsiness after eating​​​​​​​

Muscular soreness

Heart races​​​​​​​

Hyperirritable​​​​​​​

Feeling of a band around head​​​​​​​

Melancholia (feeling of sadness)​​​​​​​

Swelling of ankles​​​​​​​

Change in urinary function​​​​​​​

Tendency to consume sweets/carbohydrates​​​​​​​

Muscle spasms​​​​​​​

Blurred vision​​​​​​​

Involuntary muscle action​​​​​​​

Numbness

Night sweats

Rapid digestion​​​​​​​

Sensitivity to noise​​​​​​​

Redness of palms of hands and bottom of feet​​​​​​​

Visible veins on chest and abdomen​​​​​​​

Hemorrhoids​​​​​​​

Apprehension (feeling that something bad is going to happen)​​​​​​​

Nervousness causing loss of appetite

Nervousness with indigestion​​​​​​​

Gastritis​​​​​​​

Forgetfulness​​​​​​​

Thinning hair​​​​​​​

IMPORTANT | Please list below the five main physical complaints you have in order of their importance.

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