Patient name: ____________________________________

Date of Birth: ____________ Height: _______Weight: ______

This form is for the client. It will help you to remember what symptoms you have when you can’t remember (that’s called psychic amnesia by the way). Many clients make a list of the things they want to talk about before each consult. This teaser list will help you with that process. Please don’t mail it to me or email it though. I don’t seem to have the time to review all that info before the consult and it distracts me from my normal way of taking a history. Thanks. 

Instructions: Number the boxes that apply to you. Use (1) for MILD symptoms (occur once or twice a month), (2) for MODERATE symptoms (occur several times a month), and (3) for SEVERE symptoms (you are aware of almost constantly). We are focusing only on those issues that you have been experiencing in the last SIX months. If there are symptoms that you have experienced in the past, please mark that box with the letters (Hx) which means historically experienced. If you can remember the approximate year, go ahead and write that after the symptom.

GROUP ONE: (Sympathetic Dominance)

  1. Acid foods upset
  2. Gets chilled, often
  3. “Lump” in throat
  4. Dry mouth-eyes-nose
  5. Pulse speeds after meal
  6. Keyed up – fail to calm
  7. Cuts heal slowly
  8. Gags easily
  9. Unable to relax, startles easily
  10. Extremities cold, clammy
  11. Strong light irritates
  12. Urine amount reduced
  13. Heart pounds after retiring
  14. “Nervous” stomach
  15. Appetite reduced
  16. Cold sweats often
  17. Fever easily raised
  18. Neuralgia-like pains
  19. Staring, blinks little
  20. Sour stomach frequent

GROUP TWO: (Parasympathetic Dominance)

  21. Joint stiffness after arising
  22. Muscle-leg-toe cramps at night
  23. “Butterfly” stomach, cramps
  24. Eyes or nose watery
  25. Eyes blink often
  26. Eyelids swollen, puffy
  27. Indigestion soon after meals
  28. Always seem hungry; feels “lightheaded” often
  29. Digestion rapid
  30. Vomiting frequent
  31. Hoarseness frequent
  32. Breathing irregular
  33. Pulse slow; feels “irregular”
  34. Gagging reflex slow
  35. Difficulty swallowing
  36. Constipation, diarrhea alternating
  37. “Slow starter”
  38. Gets “chilled” infrequently
  39. Perspires easily
  40. Circulation poor, sensitive to cold
  41. Subject to colds, asthma, bronchitis

GROUP THREE (Sugar Handling)

  42. Eats when nervous
  43. Excessive appetite
  44. Hungry between meals
  45. Irritable before meals
  46. Gets “shaky” if hungry
  47. Fatigue, eating relieves
  48. “Lightheaded” if meals delayed
  49. Heart palpitates if meals missed or delayed
  50. Afternoon headaches
  51. Overeating sweets upsets
  52. Awaken after few hours sleep-hard to get back to sleep
  53. Craves candy or coffee in afternoons
  54. Moods of depression-“blues” or melancholy
  55. Abnormal craving for sweets or snacks

GROUP FOUR (Cardiovascular)

  56. Hands and feet go to sleep easily, numbness
  57. Sighs frequently, “air hunger”
  58. Aware of “breathing heavily”
  59. High altitude discomfort
  60. Opens windows in closed room
  61. Susceptible to colds and fevers
  62. Afternoon “yawner”
  63. Gets “drowsy” often
  64. Swollen ankles worse at night
  65. Muscle cramps, worse during exercise; gets “charley horses”
  66. Shortness of breath on exertion
  67. Dull pain in chest or radiating into left arm, worse on exertion
  68. Bruises easily, “black and blue” spots
  69. Tendency to anemia
  70. “Nose bleeds” frequent
  71. Noises in head, or “ringing in ears”
  72. Tension under the breastbone, or feeling of “tightness”  worse on exertion

GROUP FIVE (Liver and Gallbladder)

  73. Dizziness
  74. Dry skin
  75. Burning feet
  76. Blurred vision
  77. Itching skin and feet
  78. Excessive falling hair
  79. Frequent skin rashes
  80. Bitter, metallic taste in mouth in mornings
  81. Bowel movements painful or difficult
  82. Worrier, feels insecure
  83. Feeling queasy; headache over eyes
  84. Greasy foods upset
  85. Stools light-colored
  86. Skin peels on foot soles
  87. Pain between shoulder blades
  88. Uses laxatives
  89. Stools alternate from soft to watery
  90. History of gallbladder attacks or gallstones
  91. Sneezing attacks
  92. Dreaming, nightmare type bad dreams
  93. Bad breath (halitosis)
  94. Milk products cause distress
  95. Sensitive to hot weather
  96. Burning or itching anus
  97. Craves sweets

GROUP SIX (Digestion)

  98. Loss of taste for meat
  99. Lower bowel gas several hours after eating
  100. Burning stomach sensations, eating relieves
  101. Coated tongue
  102. Pass large amounts of foul-smelling gas
  103. Indigestion 1/2 – 1 hour after eating but sometimes up to 3-4 hours
  104. Mucous colitis or “irritable bowel”
  105. Gas shortly after eating
  106. Stomach “bloating” after eating

GROUP SEVEN (A)  (Endocrine-Hyperthyroid)

  107. Insomnia
  108. Nervousness
  109. Can’t gain weight
  110. Intolerance to heat
  111. Highly emotional
  112. Flushes easily
  113. Night sweats
  114. Thin, moist skin
  115. Inward trembling
  116. Heart palpitates
  117. Increased appetite without weight gain
  118. Pulse fast at rest
  119. Eyelids and face twitch
  120. Irritable and restless
  121. Can’t work under pressure

GROUP SEVEN (B) (Endocrine-Hypothyroid)

  122. Increase in weight
  123. Decrease in appetite
  124. Fatigues easily
  125. Ringing in ears
  126. Sleepy during day
  127. Sensitive to cold
  128. Dry or scaly skin
  129. Constipation
  130. Mental sluggishness
  131. Hair coarse, falls out
  132. Headaches upon arising-wears off during day
  133. Slow pulse, below 65
  134. Increased frequency of urination
  135. Impaired hearing
  136. Reduced initiative

GROUP SEVEN ( C ) (Endocrine-Hyperpituitary)

  137. Failing memory
  138. Low blood pressure
  139. Increased sex drive
  140. Headaches, “splitting or rendering” type
  141. Decreased sugar tolerance

GROUP SEVEN (D) (Endocrine-Hypopituitary)

  142. Abnormal thirst
  143. Bloating of abdomen
  144. Weight gain around hips or waist
  145. Sex drive reduced or lacking
  146. Tendency to ulcers, colitis
  147. Increased sugar tolerance
  148. Women: menstrual disorders
  149. Young girls: lack of menstrual function

GROUP SEVEN (E)  (Endocrine-Hyperadrenal)

  150. Dizziness
  151. Headaches
  152. Hot flashes
  153. Increased blood pressure
  154. Hair growth on face or body (female)
  155. Sugar in urine (not diabetes)
  156. Masculine tendencies (female)

GROUP SEVEN (F)  (Endocrine-Hypoadrenal)

  157. Weakness, dizziness
  158. Chronic fatigue
  159. Low blood pressure
  160. Nails, weak, ridged
  161. Tendency to hives
  162. Arthritic tendencies
  163. Perspiration increase
  164. Bowel disorders
  165. Poor circulation
  166. Swollen ankles
  167. Craves salt
  168. Brown spots or bronzing of skin
  169. Allergies-tendency to asthma
  170. Weakness after colds, influenza
  171. Exhaustion-muscular and nervous
  172. Respiratory disorders

GROUP EIGHT (B-Complex Deficiencies–Foundational Issues)

  173. Apprehension
  174. Irritability
  175. Morbid fears
  176. Never seems to get well
  177. Forgetfulness
  178. Indigestion
  179. Poor appetite
  180. Craving for sweets
  181. Muscular soreness
  182. Depression; feelings of dread
  183. Noise sensitivity
  184. Acoustic hallucinations
  185. Tendency to cry without reason
  186. Hair is coarse and/or thinning
  187. Weakness
  188. Fatigue
  189. Skin sensitive to touch
  190. Tendency toward hives
  191. Nervousness
  192. Headache
  193. Insomnia
  194. Anxiety
  195. Anorexia
  196. Inability to concentrate; confusion
  197. Frequent stuffy nose; sinus infections
  198. Allergy to some foods
  199. Loose joints

FEMALE ONLY

  200. Very easily fatigued
  201. Premenstrual tension
  202. Painful menses
  203. Menstruates too frequently
  204. Vaginal discharge
  205. Hysterectomy/ovaries removed
  206. Menopausal hot flashes
  207. Menses scanty or missed
  208. Acne, worse at menses
  209. Depression of long standing

MALE ONLY

  210.  Prostate trouble
  211.  Urination difficult or dribbling
  212.  Night urination frequent
  213.  Depression
  214. Pain on inside of legs or heels
  215. Feeling of incomplete bowel evacuation
  216. Lack of energy
  217. Migrating aches and pains
  218. Tires too easily
  219. Avoids activity
  220. Leg nervousness at night
  221. Diminished sex drive

TO THE PATIENT: Please list below the five main physical complaints you have in order of their importance to you.

1.  
2.  
3.  
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5.