Patient Symptom Survey

This is a confidential patient symptom survey. Please check each condition which is true for you. If the condition does not apply to you or you do not understand a term or if you are not sure if a condition applies to you, then do not check the box. Use common sense. For example, Insomnia once in the last month probably isn’t that important and would not be marked. However, Insomnia occurring 1-2 times per week is notable and would be marked. Please take your time…


Patient Information
Name Age
Email    
If known:
Weight Height
Blood Pressure Pulse
02 Tongue

Primary Complaints
General Good Health High Cholesteral Hyperthyroid
Desires Nutritional &
Metabolic Analysis		 High Blood Pressure Hypothyroid
Skin Disorder Low Blood Pressure Lupus
Acne Tachycardia (High Heart Rate) Infertility, female
Psoriasis Numbness Interstitial Cystitis
Urticaria (Hives) Constipation Irregular Menstrual Cycle
ADD/ADHD Indigestion Menopausal Symptoms
Allergies Ulcerative Colitis Hot Flashes
Food Allergy Depression Mental Disorder
Sinusitis Diabetes Mellitus Insomnia
Alzheimer’s Diabetes Type I Mouth/Throat/Tongue
Poor Concentration/
Memory		 Diabetes Type II Canker Sores
Parkinson’s Disease Hyperglycemia
[high blood sugar]		 Overweight
Anemia Hypoglycemia
[low blood sugar]		 Underweight
Arthritic Disorder Dizziness/Balance Problem Sexual Disorder
Osteoporosis Ear Infection Spinal Problems
Asthma Epstein Barr Obesity
Emphysema Eye Problems GERD
Cancer Cataracts HIV Infection
Breast Glaucoma Crohn’s Disease
Prostate Macular Degeneration Irritable Bowel Syndrome
Lung Fever Pregnant
Colon/Rectal Fibromyalgia Shingles
Skin Gallbladder Disorder Migraines
Leukemia Gout Rheumatoid Arthritis
Lymphoma Headaches Lupus
Brain Tumor Hearing Loss Multiple Sclerosis
Other Infertility, male ALS Lou Gerigs Disease
Anxiety/Stress Liver Disease Polymyalgia Rheumatica
Autism Hepatitis Scleroderma
Edema Hepatitis B Goiter
Eczema Hepatitis C Raynaud’s Syndrome
Chronic Fatigue Kidney/Bladder Hemochomatosis
Circulatory Disorder Prostate Disorder Thalassemia
Heart Disease Post Stroke/Brain Aneurism    
 
If necessary, please state your most significant concern

General Health

Fingernail base is pink Somewhat Underweight
Fingernail base is purple Unexplained weight loss of over 20lbs within the last 4 months
Fingernails have ridges or white spots Energy level is worse than it was 5 years ago
Fingernails are soft Sleeps less than 6 hours per night
Fingernails are splitting Unable to recall dreams the next day
Fingernails peel Sensitive to chemicals, paint, fumes, cologne
Pale fingernail beds Had blood transfusion in the past
Blacks out easily Had transplant in the past
Balance problems Takes anti-rejection drugs
Difficulty walking Had a major accident or injury
Has tattoos Sleep Apnea
Brittle hair Toxic chemical exposure
Dry hair Has been out of the country recently
Thin hair Had childhood vaccines
Hair loss Had a vaccine in the last 12 months
Drinks alcoholic beverages daily Had a flu shot last year
Drinks less than 8 glasses of water per day Had a pneumonia vaccine last year
Currently on Chemotherapy Had a Hepatitis B vaccine in the last 2 years
Currently on radiation treatment Has a family history of:
Had radiation therapy in the last year   Cancer
Had chemotherapy in the last year Heart Disease
Had chemotherapy in the past Diabetes
Has had radiation treatments in the past Alcoholism
Gained over 20 lbs in the last 12 months Depression
Somewhat Overweight Obesity

Lifestyle Habits

Drinks beverages from a can Drinks 1 or more pop/sodas
per day		 Smokes more than
1 pack per day
Drinks alcohol I had 4 alcoholic drinks in one day: Rarely exercises
Drinks caffeinated coffee   never Regularly exercises
Drinks caffeinated pop/soda more than 3 months ago Takes Vitamins
Drinks caffeinated tea less than 3 months ago Vegetarian
Drinks decaffeinated coffee Has more than 5 alcoholic
drinks per week		 Eats no red meat
Drinks decaffeinated pop/soda Craves sugar/starches Eats no meat, no dairy
Drinks decaffeinated tea Currently smokes Frequent use of artificial
sweeteners
Drinks more than 3 cups of
coffee per day		 Quit smoking in the last 5
years		 Anorexia
Drinks diet pop/soda Smoked for more than 5 years Bulimic

Surgeries
Tonsillectomy and/or Adenoids Hysterectomy, complete Extremity surgery
Appendix Hysterectomy, partial Hip replacement
Gallbladder Tubal ligation Knee replacement
Thyroid Breast implants Splenectomy
Radiated thyroid Coronary by-pass Cataract surgery
Cancer Spinal surgery Hemorrhoidectomy

Gastrointestinal
4-5 bowel movements per week Immediate indigestion upon eating
3 or less bowel movements per week Indigestion in 2 hours or more after meals
6 or more bowel movements per week Indigestion within 1 hour after meals
Black tarry stools Difficulty swallowing
Pale or yellow colored stool Eating relieves fatigue
Bloody stools Eats when nervous
Constipation Excessive hunger
Hemorrhoids Poor appetite
Loose bowel movements Experiences fainting spells when hungry
Frequent diarrhea Feels shaky when hungry
Frequent nausea Frequently drowsy after eating a meal
Frequent vomiting Gall bladder disease
Abdominal gas Has had intestinal worms
Belching and burping after eating Reflux/Hiatal hernia
Bloated after eating Liver disease
Severe abdominal pains Irritable Bowel Syndrome
Stomach ulcers Diverticulitis
Uses digestive aids Diverticulosis
Uses laxatives  

Respiratory
Catches severe colds Frequent colds Night sweats
Chronic chest condition Frequent nose bleeds Post nasal drip
Chronic cough Frequent sinus infections Sneezing spells
Constant runny nose Frequent stuffy nose Spits up blood
COPD Hay fever Spits up phlegm
Difficulty breathing Nasal polyps Wheezes

Mouth and Throat

Bad breath Frequent fever blisters Tongues has grooves or fissures
Bitter taste in the mouth in the morning Frequent sore throats Tongue is coated
Dry mouth Frequently has a sore tongue Gums bleed when brushing teeth
Excessive saliva Sore gums Toothaches
Sores or cracks in the
corners of the mouth		 Swollen gums Amalgam dental fillings
Glands often swell Swollen tongue Other dental fillings
(gold, composite, etc.)
Frequent canker sores Tongue burns Has had root canals

Endocrine
Coarse hair Frequently feels hot
Coarse skin Gets lightheaded when standing quickly
Diabetic Heals slowly
Excessive thirst Unusually jumpy or nervous
Frequently feels cold Unusually tired most of the time

Cardiovascular
Cold feet Pain in leg/hips when walking
Cold hands Frequent swollen ankles
Experiences shortness of breath while sitting still Pains in the heart or chest
Heart skips beats Spells of rapid heart rate
Tendency of high blood pressure Troubled with blood clots
Leg cramps during bedtime Unusually slow pulse rate
Leg cramps during daytime Varicose veins
Low blood pressure at times Heart palpitations

Skin
Bruises easily Hives Skin eruptions
Excessive perspiration Itchy skin Skin is tender
Frequent goose bumps Problems with Eczema Sores that heal slowly
Has acne Has moles which are changing in size and/or color Troubled with boils
Has Psoriasis Skin is rough, especially on the back of the arms Dry skin

Ears
Discharge from ears Punctured ear drum Ringing or noises in the ears
Hard of hearing Recurrent ear infection Tinnitus

Eyes
Bloodshot eyes Eyes watery Mild Macular degeneration
Blurred vision Blurred vision Itchy eyes
Cross eyes Far sighted Near sighted
Eye pain Developing cararacts Dry eyes
Eyes feel gritty        

Feet
Corns Painful feet Plantar fascitis
Frequent foot cramps Plantar warts Fungal infection
Heal spurs Swelling in the feet and/or ankles    

Neuromuscular
Bites nails Has motion sickness Low back pain
Frequent muscle soreness Has Osteoarthritis Neck pain
Muscle spasms Has Rheumatism   Pain between the shoulders
Muscle weakness Rheumatoid Arthritis Shoulder/arm pain
Tremors Joint stiffness in the morning Numbness/tingling in the body
Frequent headaches Swollen joints Sleep walks
Often dizzy Leg pain at rest Stutters or stammers
Frequently feels faint Spinal curvatures Nerve pain
Has Epilepsy        

Behavior Patterns
Afraid to eat anywhere except home Often annoyed by people
Always needs someone to advise Recurrent bad dreams
Cries often Sometimes wishes to be dead or away from it all
Difficulty concentrating Upset by criticism
Difficulty falling asleep Poor memory
Difficulty staying asleep Scared to be alone
Easily angered Strange people or places cause fear
Feelings are easily hurt Under considerable emotional stress
Frequently becomes scared for no reason   Unhappy when others are happy
Frequently miserable or blue Brain fog
Has to be on guard even with friends    

Urinary
Urinates more than 2 times per night Troubled by urgent urnination
Bed wetting Incontinence when sneezing or laughing
Blood in the urine Loses bladder control
Difficulty starting urination Frequent bladder infections
Painful urination Frequent kidney infections
Frequent urination Kidney stones

Men Only

Difficulty completing intercourse Painful genitals
Difficulty getting or keeping an errection Prostate troubles
Discharge from urethra Sores on external genitalia
Had a vasectomy Herpes
Had difficulty fathering children Sexual diseases
Lumps in the testicles    

Women Only

Heavy hair growth on face or body Lumps in the breasts
Cycles are every 27-29 days Tender breasts
Abnormal cycle >29 days and/or <26 days Vaginal discharge
PMS Bloody spotting discharge
Menstrual cramps Yeast infections
Painful periods Sores on external genitalia
Acne worse at menstruation   Herpes
Excessive menstrual flow Sexual diseases
Retains fluid during periods Endometriosis
Pre-menstrual depressions Breast reduction
Currently taking birth control medication Breast augmentation
Has taken birth control medication more than 1 year Abortion
Has taken birth control medication within the last year D&C
Has had miscarriage Tubal pregnancy
Hot flashes Uterine fibroids
Takes hormone replacement medication Ovarian fibroids
Diminshed sexual desire Breast fibroids
Painful intercourse Currently breastfeeding
Poor or infrequent orgasm    

Please list all drugs you are currently taking including over the counter drugs, aspirin, etc. Also list how long you have taken each drug and the condition for which it was prescribed.

 

Please list all drugs taken within the last year including over the counter drugs, antibiotics, aspirin, inhalers, etc. Also, list how long you have taken each drug and the condition for which it was prescribed.

 

Please list all vitamins/herbs/supplements you are currently taking. Also, list how much of each supplement you are taking.