Nutritional Symptom Survey

*Patient  

Age         

Doctor    

*Email      

Phone #  

INSTRUCTIONS: Select the number that applies to you. If a symptom does not apply, leave it blank.
Select either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occurs several times a month), or (3) for SEVERE symptoms (occurs almost constantly).

GROUP ONE

1. Dry mouth-eyes-nose
2. Cuts heal slowly
3. Unable to relax, startles easily
4. Strong light irritates
5. Sour stomach frequent

GROUP TWO

6. Joint stiffness after arising
7. Muscle-leg-toe cramps at night
8. Eyes or nose watery
9. Eyes blink often
10. Always seem hungry: feels "lightheaded" often
11. Constipation, diarrhea alternating
12. "Slow stater"

GROUP THREE

13. Eat when nervous
14. Excessive appetite
15. Hungry between meals
16. Irritable before meals
17. Get "shaky" if hungry
18. Fatigue, eating relieves
19. "Lightheaded" if meals delayed
20. Heart palpitates if meals missed or delayed
21. Afternoon headaches
22. Overeating sweets upsets
23. Awaken after few hours sleep - hard to
get back to sleep
24. Crave candy or coffee in afternoons
25. Moods of depression "blues" or melancholy
26. Abnormal craving for sweets or snacks

GROUP FOUR

27. Aware of "breathing heavily"
28. Swollen ankles worse at night
29. Muscle cramps, worse during exercise;
get "charley horses"
30. Tension under the breastbone, or feeling of "tightness",
worse on exertion

GROUP FIVE

31. Itching skin and feet
32. Frequent rashes
33. Greasy foods upset
34. Stools light-colored
35. Pain between shoulder blades
36. Use laxatives
37. History of gallbladder attacks or gallstones
38. Milk products causes distress

GROUP SIX

39. Mucous colitis or "irritable bowel"
40. Gas shortly after eating
41. Stomach "bloating" after eating

GROUP SEVEN

42. Insomnia
43. Highly emotional
44. Inward trembling
45. Heart palpitates
46. Increased appetite without weight gain
47. Pulse fast at rest
48. Eyelids and face twitch
49. Irritable and restless
50. Decrease in appetite
51. Fatigue easily
52. Sleepy during the day
53. Sensitive to cold
54. Dry or scaly skin
55. Constipation
56. Hair coarse, falls out
57. Reduced initiative
58. Hot flashes
59. Increased blood pressure
60. Hair growth on face or body (female)
61. Masculine tendencies (female)
62. Chronic fatigue
63. Low blood pressure
64. Tendency to hives
65. Arthritic tendencies
66. Swollen ankles
67. Crave salt
68. Brown spots or bronzing of skin
69. Allergies - tendency to asthma
70. Exhaustion - muscular and nervous
71. Respiratory disorders

GROUP EIGHT

72. Depression; feelings of dread
73. Tendency to cry without reason
74. Skin sensitive to touch
75. Nervousness
76. Insomnia
77. Anxiety

FEMALE ONLY

78. Premenstrual tension
79. Painful menses
80. Painful breasts
81. Hysterectomy/ovaries removed
82. Menopausal hot flashes

MALE ONLY

83. Prostate trouble
84. Urination difficult or dribbling
85. Night urination frequent
86. Lack of energy
87. Avoids activity

IMPORTANT

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

1.  

2.  

3.  

4.  

5.