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Instructions:
Answer the following by answering the following
question with: 0-none (default), 1-mild, 2-moderate, or 3-Severe
1 - MILD
symptoms (once or twice last 6 month)
2 - MODERATE symptoms (once or twice last month)
3 - SEVERE symptoms (Chronic, once or twice last week)
Skip,
if question does not apply to you!
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Group
1: Sympathetic Dominance
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1.
Acid foods upset |
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2.
Feel chilled often |
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3.
"Lump" in throat |
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4.
Dry mouth-eyes-nose |
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5.
Pulse speeds up after meals |
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6.
Keyed up; unable to feel calm |
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7. Cuts heal slowly |
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8. Gag easily |
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9. Unable to relax; startles easily |
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10. Extremities cold and/or clammy |
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11. Strong light irritates |
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12. Urine amount reduced |
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13. Heart pounds after retiring |
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14. "Nervous" stomach |
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15. Appetite reduced |
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16. Cold sweats often |
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17. Body temperature rises easily |
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18. Skin sensitive to touch |
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19. Staring, blinks little |
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20. frequently have a sour stomach |
Group
2 Parasympathetic Dominance
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21.
Joint stiffness after arising |
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22. Muscle-leg-toe cramps at night |
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23. "Butterfly" stomach cramps |
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24. Eyes or nose watery |
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25. Eyes blink often |
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26. Eyelids swollen or puffy |
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27. Indigestion soon after meals |
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28. Always seem hungry; 'lightheaded' often |
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29. Food digest rapidly |
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30. Vomit frequently |
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31. Frequently hoarse |
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32. Irregular breathing |
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33. Pulse slow or feels "irregular" |
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34. Slow gag reflex |
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35. Difficulty swallowing |
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36. Alternating constipation and diarrhea |
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37. "Slow starter" |
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38. Not easily chilled |
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39. Perspire easily |
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40. Poor circulation or sensitive to cold |
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41. Subject to colds, asthma, bronchitis |
Group
3: Sugar Handling
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42.
Eat when nervous |
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43. Excessive appetite |
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44. Hungry between meals |
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45. Irritable before meals |
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46. Get "shaky" if hungry |
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47. Feeling fatigued, eating relieves |
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48. "Lightheaded" if meals delayed |
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49. Heart palpitates if meals delayed |
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50. Afternoon headaches |
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51. Upset feeling from excessive sweet eating |
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52. Awaken after a few hours of sleep, hard to get back to
sleep |
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53. Crave candy or coffee in afternoon |
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54. Moods or depression, "blues", or melancholy |
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55. Abnormal cravings for sweets or snacks |
Group
4: Cardiovascular
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56.
Hands and feet go to sleep easily, numbness |
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57. Sigh frequently, "air hunger" |
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58. Aware of "breathing heavily" |
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59. Discomfort in high altitude |
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60. Opens windows in closed room |
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61. Susceptible to colds and fevers |
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62. Afternoon "yawner" |
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63. Get "drowsy" often |
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64. Swollen ankles worse at night |
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65. Muscle cramps, worse during exercise; "charley-horses" |
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66. Shortness of breath on exertion |
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67. Dull pain in chest or radiation into left arm, worse on
exertion |
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68. Bruise easily, "black/blue" spots on arms or legs |
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69. Tendency to anemia |
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70. Frequently have "nose bleeds" |
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71. "Ringing in ears" or noises in head |
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72. Tension under the breast-bone or felling of "tightness
in chest" |
Group
5: Liver/Biliary
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73.
Dizziness |
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74. Dry skin |
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75. Burning feet |
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76. Blurred vision |
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77. Itching skin and feet |
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78. Excessive falling out hair |
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79. Frequent skin rashes |
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80. Bitter or metallic taste in mouth in the mornings |
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81. Bowel movements painful or difficult |
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82. Feelings of worry, dread, or insecurity |
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83. Feeling queasy; headache over eyes |
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84. Greasy foods upset |
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85. Stools light-colored |
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86. Skin peels on foot soles |
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87. Pain between shoulder blades |
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88. Using laxatives |
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89. Stools alternate from soft to watery |
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90. History of gallbladder attacks or gall stones |
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91. Sneezing attacks |
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92. Dreaming, nightmare-type bad dreams |
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93. Bad breath (halitosis) |
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94. Milk products cause distress |
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95. Sensitive to hot weather |
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96. Burning or itching anus |
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97. Crave sweets |
Group
6: Digestion
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98.
Loss of taste for Meat |
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99. Lower bowel gas several hours after eating |
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100. Burning stomach sensations, eating relieves |
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101. Coated Tongue |
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102. Pass large amounts of foul smelling gas |
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103. Indigestion ½-1 hours after eating; may be up to 3-4
hours |
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104. Mucus colitis or "Irritable bowel" |
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105. Gas shortly after eating |
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106. Stomach "bloating" after eating |
Group
7A: Hyperthyroid
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107.
Insomnia |
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108. Nervousness |
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109. Can't gain weight |
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110. Intolerance to heat |
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111. Highly emotional |
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112.
Flush easily |
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113. Night Sweats |
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114. Skin is thin and moist |
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115. Inward trembling |
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116. Heart Palpitations |
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117. Increase appetite without weight gain |
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118. Pulse races when resting |
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119. Eyelids and face twitch |
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120. Irritable and restless |
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121. Can't work under pressure |
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Group
7B: Hypothyroid
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122.
Noticeable weight gain |
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123. Decrease in appetite |
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124. Easily Fatigued |
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125. Ringing in ears |
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126. Sleepy during day |
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127. Sensitive to cold |
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128. Dry or scaly skin |
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129. Constipation |
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130. Mental sluggishness |
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131. Hair coarse, falls out |
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132. Headaches upon arising wear off during day |
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133. Slow pulse, below 65 |
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134. Frequent urination |
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135. Impaired hearing |
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136. reduced initiative |
Group
7C: Hyperpituitary
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137.
Failing Memory |
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138. Low Blood pressure |
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139. Increased sex drive |
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140. Headaches, "splitting or rendering" type |
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141. Decrease Sugar tolerance |
Group
7D: Hypopituitary
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142.
Abnormal thirst |
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143. Bloating of the abdomen |
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144. Weight gain around hips or waist |
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145. Sex drive reduced or lacking |
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146. Tendency toward ulcers and/or colitis |
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147. Increased sugar tolerance |
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148. (FEMALE) Menstrual disorders |
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149. (Young Girls) Lack of menstrual function |
Group
7E: Hyperadrenal
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150.
Dizziness |
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151. Headaches |
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152. Hot flashes |
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153. Increased blood pressure |
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154. (FEMALE) Hair growth on face or body |
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155. Sugar in urine (not diabetes) |
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156. (FEMALE) Masculine tendencies |
Group
7F: Hypoadrenal
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157.
Weakness and/or dizziness |
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158. Chronic fatigue |
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159. Low blood pressure |
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160. Nails weak and/or ridged |
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161. Tendency toward hives |
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162. Arthritic Tendencies |
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163. Perspiration increase |
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164. Bowel disorders |
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165. Poor circulation |
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166. Swollen ankles |
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167. Crave Salt |
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168. Brown spots or bronzing of skin |
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169. Allergies - tendency towards asthma |
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170. Weakness after colds or influenza |
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171. Muscular and nervous exhaustion |
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172. Respiratory disorders |
Group
8: Foundational Issues
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173.
Apprehension |
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174. Irritability |
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175. Morbid fears |
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176. Never seems to get well |
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177. Forgetfulness |
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178. Indigestion |
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179. Poor appetite |
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180. Craving for sweets |
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181. Muscular soreness |
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182. Depression; feelings of dread |
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183. Noise sensitivity |
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184. Acoustic hallucinations |
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185. Tendency to cry without reason |
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186. Hair is coarse and/or thinning |
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187. Weakness |
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188. Fatigue |
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189. Skin sensitive to touch |
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190. Tendency toward hives |
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