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Symptom Survey form
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The Secret

Symptom Survey Form

INSTRUCTIONS: E-mail Submission
Enter your name, birth date, date, 3 main health problems, email, gender and whether or not you are a vegetarian  in the fields below. Then, using the response key which follows, enter a value in each of the spaces provided. When you're finished, press the Submit button at the bottom of the page.

RESPONSE KEY: Please use only these numbers. Leave the entry blank if the symptom does not apply to you. (1) for MILD symptoms (occurring 1-2 times per year), (2) for MODERATE symptoms (occurring many times during the year, (3) for SEVERE symptoms (occurring most of the time)

INSTRUCTIONS: Fax Submission
First, print the entire form to your printer using your browser's Print command (usually found under the "File" heading.) Fill out all the required information (using black or blue pen) and fax the entire form to:

Dr. Karl R.O.S. Johnson at (586) 731-9550. (If faxing from outside the United States, don't forget to add the required international dialing prefix for the United States!)

RESPONSE KEY: Please use only these numbers. Leave the entry blank if if the symptom does not apply to you. (1) for MILD symptoms (occurring 1-2 times per year), (2) for MODERATE symptoms (occurring many times during the year, (3) for SEVERE symptoms (occurring most of the time)
 

These items are needed to properly complete your report.  If any items are missing I will not be able to complete your report.  Thank You.
Name:

Date:

Main 3 Health Problems:

Birth date:

E-mail address:

Gender:

Phone Number:

Vegetarian:

 

By filling out this form, you agree to release your personal information to Karl R.O.S. Johnson, D.C.

GROUP ONE

 1 Acid foods upset
 2 Get 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 Gag 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

 21 Joint stiffness after arising
 22 Muscle-leg-toe cramp, 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 seems 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 Get "chilled" infrequently
 39 Perspire easily
 40 Circulation poor,
       sensitive to cold
 41 Subject to colds,
       asthma, bronchitis

GROUP THREE

 42 Eat when nervous
 43 Excessive appetite
 44 Hungry between meals
 45 Irritable before meals
 46 Get "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 Crave candy or coffee
       in afternoons
 54 Moods of depression -
       "blues" or melancholy
 55 Abnormal craving for
       sweets or snacks

GROUP FOUR

 56 Hands and feet go to sleep
       easily, numbness
 57 Sigh 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 Get "drowsy" often
 64 Swollen ankles
       worse at night
 65 Muscle cramps,worse
       during exercise; get
       "charley horses"
 66 Shortness of breath
       on exertion
 67 Dull pain in chest or
       radiating into left arm,
       worse on exertion
 68 Bruise 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

 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 Use 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 Crave sweets

GROUP SIX

 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; may be up to 3-4 hrs.
 104 Mucous colitis or
        "irritable bowel"
 105 Gas shortly after eating
 106 Stomach "bloating"
        after eating

GROUP SEVEN (A)

 107 Insomnia
 108 Nervousness
 109 Can't gain weight
 110 Intolerance to heat
 111 Highly emotional
 112 Flush 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)

 122 Increase in weight
 123 Decrease in appetite
 124 Fatigue 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
        wear off during day
 133 Slow pulse, below 65
 134 Frequency of urination
 135 Impaired hearing
 136 Reduced initiative

GROUP SEVEN (C)

 137 Failing memory
 138 Low blood pressure
 139 Increased sex drive

 140 Headaches, "splitting
        or rending" type
 141 Decreased sugar
        tolerance

GROUP SEVEN (D)

 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)

 150 Dizziness
 151 Headaches
 152 Hot flashes
 153 Increased blood
        pressure

 154 Hair growth on lace
        or body (female)
 155 Sugar in urine
        (not diabetes)
 156 Masculine tendencies
        (female)

GROUP SEVEN (F)

 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 Crave 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

 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 or thinning
 187 Weakness
 188 Fatigue
 189 Skin sensitive to touch
 190 Tendency towards 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 menses
 203 Depressed feelings before menstruation
 204 Menstruation excessive and prolonged
 205 Painful breasts
 206 Menstruate too frequently
 207 Vaginal discharge
 208 Hysterectomy/ovaries removed
 209 Menopausal hot flashes
 210 Menses scanty or missed
 211 Acne, worse at menses
 212 Depression of long standing

MALE ONLY

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

All finished? Then, press Submit to send the results (by e-mail) to Dr. Karl R.O.S. Johnson. (Fax submitters should not use this button!) Pressing Reset will clear the form and allow you to start again.

For more information, please contact Dr. Karl R.O.S. Johnson at the Chiropractic & Nutrition Wellness Center by phone at (586) 731-8840 or by e-mail at info@wellnesschiro.com.

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Last modified: January 01, 2008

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