Sample Questionaire Only
Health Questionaire FORM
(Partial Survey)
Patient____________________Date____________________________
Birth Date___/____/_____ Approx Weight______ Vegetarian: YesNo
Sex: Male Female
INSTRUCTIONS: Fill in only the squares which apply to you.
MILD symptoms (occurred once or twice last 6 months). Square 1
MODERATE symptoms (occurred once or twice last month). Square 2
SEVERE symptoms (chronic, occurred once or twice last week). Square 3
Leave Squares BLANK if they don't apply to you!
GROUP 1
1 2 3
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 Cut heals 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 often
GROUP 2
1 2 3
21 Joint stiffness on 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 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