INSTRUCTIONS: 1). Print this form by clicking the "PRINT" button on your toolbar. 2). Place an "X" in the boxes by the symptoms that you notice on a consistent basis. 3). Mail completed form to:
DIRECTIONS FOR THE SYMPTOM SURVEY FORM
1.
Fill in the date, your name, age, surgeries, medications and
supplements.
2.
Place an “X” in any and all of the boxes by the symptoms that you
have on a
daily/weekly basis only.
3.
Complete the Barnes Thyroid Test at the bottom of the third page.
(Even if you do or
do not have a thyroid problem.
4.
Write down everything you eat/drink for one week.
List any symptoms you may
have at the bottom.
5.
Have your blood pressure taken sitting, then immediately standing.
Record it.
6.
Have your pulse taken sitting, then standing also.
Record it.
7.
Complete the Iodine Patch Test.
After
you have completed the above list, please return the form in the enclosed
envelope with a check or money order for $50.
A cassette analysis specifically designed for you with recommendations
for a healthier you will be promptly sent.
The
products will primarily come from Standard Process Labs, a time tested and
proven truly natural supplement company that supplies natural health care
providers; Essentially Yours, Biotics & Omega nutrition.
I will give you the option to purchase the products from our office or
the source of your choice.
SYMPTOM SURVEY FORM
INSTRUCTIONS: 1). Print this form by clicking the "PRINT" button on your toolbar. 2). Place an "X" in the boxes by the symptoms that you notice on a consistent basis. 3). Mail completed form to:
NAME: _________________________________________ AGE: __________ DATE: __________________ SURGERIES: _____________________________________________________________________________ MEDICATIONS: __________________________________________________________________________ SUPPLEMENTS: __________________________________________________________________________ (If necessary, attach additional sheet.)
GROUP ONE |
| 1. q Acid foods upset 2. q Get chilled, often 3. q "Lump" in throat 4. q Dry mouth-eyes-nose 5. q Pulse speeds after meal 6. q Keyed up - fail to calm 7. q Cuts heal slowly |
8. q Gag easily 9. q Unable to relax; startles easily 10. q Extremities cold, clammy 11. q Strong light irritates 12. q Urine amount reduced 13. q Heart pounds after retiring 14. q "Nervous" stomach |
15. q Appetite reduced 16. q Cold sweats often 17. q Fever easily raised 18. q Neuralgia-like pains 19. q Staring, blinks little 20. q Sour stomach frequent |
GROUP TWO |
21. q
Joint stiffness after arising |
28. q
Always seems hungry; |
36. q Constipation, diarrhea alternating 37. q "Slow starter" 38. q Get chilled frequently 39. q Perspire easily 40. q Circulation poor, sensitive to cold 41. q Subject to colds, asthma, bronchitis |
GROUP
THREE |
42. q
Eat when nervous |
49. q Heart palpitates if meals . missed or delayed 50. q Afternoon headaches 51. q Overeating sweets upsets 52. q Awaken after few hours sleep - hard to get back to sleep |
53. q Crave candy or coffee in afternoons 54. q Moods of depression - "blues" or melancholy 55. q Abnormal craving for sweets or snacks |
GROUP FOUR |
| 56. q Hands and feet go to sleep
easily, numbness 57. q Sigh frequently, "air hunger" 58. q Aware of "breathing heavily" 59. q High altitude discomfort 60. q Open windows in closed room 61. q Susceptible to colds/fevers 62. q Afternoon "yawner" |
63. q Get "drowsy" often 64. q Swollen ankles - worse at night 65. q Muscle cramps, worse during exercise; get "charley horses" 66. q Shortness of breath on exertion 67. q Dull pain in chest or radiating into left arm, worse on exertion |
68. q Bruise easily, "black and blue" spots 69. q Tendency to anemia 70. q "Nose bleeds" frequent 71. q Noises in head, or "ringing in ears" 72. q Tension under the breastbone, or feeling of "tightness", worse on exertion |
GROUP FIVE |
| 73. q Dizziness 74. q Dry skin 75. q Burning feet 76. q Blurred vision 77. q Itching skin and feet 78. q Excessive falling hair 79. q Frequent skin rashes 80. q Bitter, metallic taste in mouth in mornings 81. q Bowel movements painful or difficult |
82. q
Worrier, feels insecure 83. q Feeling queasy; headache over eyes 84. q Greasy foods upset 85. q Stools light-colored 86. q Skin peels on foot soles 87. q Pain between shoulder blades 88. q Use laxatives 89. q Stools alternate from soft to watery |
90. q
History of gallbladder attacks or gallstones 91. q Sneezing attacks 92. q Dreaming, nightmare/ bad dreams 93. q Bad breath (halitosis) 94. q Milk products cause distress 95. q Sensitive to hot weather 96. q Burning or itching anus 97. q Crave sweets |
|
| 98. q Loss of taste for meat 99. q Lower bowel gas several hours after eating 100. q Burning stomach sensations, eating relieves |
101. q Coated tongue 102. q Pass large amounts of foul-smelling gas 103. q Indigestion ½ - 1 hour after eating; may be up to 3-4 hrs. |
104. q Mucous colitis or "irritable bowel" 105. q Gas shortly after eating 106. q Stomach "bloating" after eating |
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GROUP EIGHT |
||
|
q
Noise sensitivity q Acoustic hallucinations q Tendency to cry without reason q Feeling something dreadful will happen q Weakness q Fatigue q Neuralgia q Neuritis |
q
Nervousness q Headache q Insomnia q Anxiety q Anorexia q Distraction q Confusion q Dizziness q Instability |
FEMALE |
ONLY | MALE ONLY |
|
| 173. q Very easily fatigued 174. q Premenstrual tension 175. q Painful menses 176. q Depressed feelings before menstruation 177. q Menstruation excessive and prolonged 178. q Painful breasts
|
179. q Menstruate too frequently 180. q Vaginal discharge 181. q Hysterectomy/ovaries removed 182. q Menopausal hot flashes 183. q Menses scanty or missed 184. q Acne, worse at menses 185. q Depression of long standing
|
186. q Prostate trouble |
_______________ Hours |
BARNES THYROID TEST
This test was developed by Dr. Broda Barnes, M.D., and is a measurement of
the underarm temperature to determine hypo and hyperthyroid states. The test
is conducted by the patient in the a.m. before leaving bed – with the
temperature being taken for 10 minutes. The test is invalidated if the
patient expends any energy prior to taking the test – getting up for any
reason, shaking down the thermometer, etc. It is important that the test be
conducted for exactly 10 minutes, making the prior positioning of both the
thermometer and a clock important.
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Patient’s Name: ________________________________ Dates: From __________ To __________
(Be
sure to list all foods and beverages consumed each day of this Diet
Report.)
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1st
Day |
2nd
Day |
3rd
Day |
4th
Day |
5th
Day |
6th
Day |
7th
Day |
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Morning Meal |
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Noon Meal |
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Evening Meal |
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Foods
& Beverages Used
at Other
Times |
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SYMPTOMS |
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