Sample Questionaire Only

Health Questionaire FORM

 (Partial Survey)

Patient____________________Date____________________________

Birth Date___/____/_____ Approx Weight______ Vegetarian: YesNo

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