computerized nutritional survey

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INSTRUCTIONS: Check the boxes which apply to you. 
Use (1) for MILD symptoms, (2) for MODERATE symptoms, and (3) for SEVERE symptoms.

use: if: description:
1 MILD - occur once or twice a year
2 MODERATE - occur several times a year
3 SEVERE - you are aware of it almost constantly

 

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GROUP 1
Acid foods upset Get chilled often "Lump" in throat
Dry mouth-eyes-nose Pulse speeds after meal Keyed up - fail to calm
Cuts heal slowly Gag easily Unable to relax; startles easily
Extremities cold, clammy Strong light irritates Urine amount reduced
Heart pounds after retiring "Nervous" stomach" Appetite reduced
Cold sweats often Fever easily raised Neuralgia-like pains
Staring, blinks little Sour stomach often  

 

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 seems hungry; feels "lightheaded" often Digestion rapid
Vomiting frequent Hoarseness frequent Breathing irregular
Pulse slow; feels "irregular" Gagging reflex slow Difficulty swallowing
Constipation, diarrhea alternating "Slow starter" Get chilled infrequently
Perspire easily Circulation poor, sensitive to cold   Subject to colds, asthma, bronchitis

 

GROUP 3
Eat when nervous Excessive appetite Hungry between meals
Irritable before meals Get "shaky" if hungry Fatigue, eating relieves
"Lightheaded" if meals delayed Heart palpitates if meals missed or delayed Afternoon headaches
Overeating sweets upsets Awaken after few hours sleep - hard to get back to sleep Crave candy or coffee in afternoons
Moods of depression - "blues" or melancholy Abnormal craving for sweets or snacks  

 

GROUP 4
Hands & feet go to sleep easily, numbness Sigh frequently, "air hunger" Aware of "breathing heavily"
High altitude discomfort Opens windows in closed room Susceptible to colds & fevers
Afternoon "yawner" Get "drowsy" often Swollen ankles worse at night
  Muscle cramps, worse during exercise; get "charley horses" Shortness of breath on exertion Dull pain in chest or radiating into left arm, worse on exertion
Bruise easily, "black & blue" spots Tendency to anemia "Nose bleeds" frequent
Noises in head, or "ringing in ears" Tension under the breastbone, or feeling of "tightness", worse on exertion  

 

GROUP 5
Dizziness Dry skin Burning fever
Blurred vision Itching skin & feet Excessive failing hair
Frequent skin rashes Bitter, metallic taste in mouth in mornings Bowel movements painful or difficult
Worrier, feel insecure Feeling Queasy; headache over eyes Greasy foods upset
Stools light-colored Skin peels on foot soles Pain between shoulder blades
Use laxatives Stools alternate from soft to watery History of gallbladder attacks or gallstones
Sneezing attacks Dreaming, nightmare type bad dreams Bad breath (halitosis)
Milk products cause distress 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
Mucous colitis or "irritable bowel" Gas shortly after eating Stomach "bloating" after eating

 

GROUP 7 (a)
Insomnia Nervousness Can't gain weight
Intolerance to heat Highly emotion Flush easily
Night sweats Thin, moist skin Inward trembling
Heart palpitates Increased appetite without weight gain Pulse fast at rest
Eyelids and face twitch Irritable and restless Can't work under pressure

 

GROUP 7 (b)
Increase in weight Decrease in appetite Fatigue easily
Ringing in ears Sleepy during day Sensitive to cold
Dry or scaly skin Constipation Mental sluggishness
Hair coarse, falls out Headaches upon arising wear off during day Slow pulse, below 65
Frequency of urination Impaired hearing Reduced initiative

 

GROUP 7 (c)
Failing memory Low blood pressure Increased sex drive
Headaches, "splitting or rending" type Decreased sugar tolerance  

 

GROUP 7 (d)
Abnormal thirst Bloating of abdomen Weight gain around hips or waist
Sex drive reduced or lacking Tendency to ulcers, colitis Increased sugar tolerance
Women: menstrual disorders Young girls: lack of menstrual function  

 

GROUP 7 (e)
Dizziness Headaches Hot flashes
Increased blood pressure Hair growth on face or body (female) Sugar in urine (not diabetes)
Masculine tendencies (female)    

 

GROUP 7 (f)
Weakness, dizziness Chronic fatigue Low blood pressure
Nails weak, ridged Tendency to hives Arthritic tendencies
Perspiration increase Bowel disorders Poor circulation
Swollen ankles Crave salt Brown spots or bronzing of skin
Allergies - tendency to asthma Weakness after colds, influenza Exhaustion - muscular & nervousness
Respiratory disorders    

 

GROUP 8
Apprehension Irritability Morbid fears
Never seems to get well Forgetfulness Indigestion
Poor appetite Craving for sweets Muscular soreness
Depression; feelings of dread Noise sensitivity Acoustic hallucinations
Tendency to cry without reason Hair is coarse and/or thinning Weakness
Fatigue Skin sensitive to touch Tendency toward hives
Nervousness Headache Insomnia
Anxiety Anorexia Inability to concentrate; confusion
Frequent stuffy nose; sinus infections Allergy to some foods Loose joints

 

Female Only
Very easily fatigued Premenstrual tension Painful menses
Depressed feelings before menstruation Menstruation excessive & prolonged Painful breasts
Menstruation too frequently Vaginal discharge Hysterectomy/ ovaries removed
Menopausal hot flashes Menses scantly or missed Acne, worse at menses
Depression of long standing    

 

Male Only
Prostate trouble Urination painful or dribbling Night urination frequent
Depression Pain on inside of legs or heels Feeling of incomplete bowel evacuation
Lack of energy Migrating aches & pains Tire too easily
Avoids activity Leg nervousness at night Diminished sex drive

 

IMPORTANT
TO THE PATIENT:  Please list below the five (5) main physical complaints you have in order of their importance.
1.
2.
3.
4.
5.

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