SYMPTOM SURVEY FORM Name Date Birth Date / / Sex: Male Female Age Blood Type INSTRUCTIONS: Fill in only the circles which apply to you. O O Mild Symptoms (occurred once or twice last 6 months) O O MODERATE symptoms (occurred once or twice in last month) O O SEVERE symptoms (chronic, occurred once or twice in last week) O O O Leave circles BLANK if they don't apply to you! Group 1 1. O O O Acid foods upset 2. O O O Get chilled often 3. O O O Dry mouth eyes-nose 4. O O O Keyed up fail to calm 5. O O O Cut heals slowly 6. O O O Unable to relax; startles easily 7. O O O Heart pounds after retiring 8. O O O Nervous stomach 9. O O O Appetite reduced 10. O O O Cold sweats often 11. O O O Neuralgia-like pains Dr. Notes: _ Group 2 12. O O O Joint stiffness on arising 13. O O O Muscle-leg-toe cramps at night 14. O O O Eyes or nose watery 15. O O O Eyelids swollen, puffy 16. O O O Indigestion soon after meals 17. O O O Always seems hungry; feels lightheaded often 18. O O O Digestion rapid 19. O O O Constipation, diarrhea alternating 20. O O O Perspire easily 21. O O O Circulation poor, sensitive to cold 22. O O O Subject to colds, asthma, bronchitis, fever Dr. Notes: _ Group 3 23. O O O Eat when nervous 24. O O O Excessive appetite 25. O O O Hungry between meals 26. O O O Irritable before meals 27. O O O Get shaky if hungry 28. O O O Fatigue, eating relieves 29. O O O Lightheaded if meals delayed 30. O O O Afternoon headaches 31. O O O Overeating sweets upsets 32. O O O Awaken after few hours sleep 33. O O O Crave candy or coffee in afternoon 34. O O O Moods of depression- blues or melancholy 35. O O O Abnormal cravings for sweets or snacks Group 4 36. O O O Hands and feet go to sleep easily, numbness 37. O O O Sigh frequently, air hunger 38. O O O Afternoon yawner 39. O O O Get drowsy often 40. O O O Swollen ankles, worse at night 41. O O O Muscle cramps, worse during night; get charley horses 42. O O O Shortness of breath on exertion 43. O O O Dull pain in chest or radiating into left arm, worse on exertion 44. O O O Bruise easily, black and blue" spots 45. O O O Tendency to anemia 46. O O O Nose bleeds frequent 47. O O O Noises in head or ringing in ears 48. O O O Tension under the breastbone, or feeling of tightness, worse on exertion Office use only: Symptom Survey FILE: Right side of chart under Progress Notes. It should be on top of Nutritional Consultation
Group 5 49. O O O Dry skin 50. O O O Burning feet 51. O O O Blurred vision 52. O O O Itching skin and feet 53. O O O Frequent skin rashes 54. O O O Bitter, metallic taste in mouth in mornings 55. O O O Bowel movements painful or difficult 56. O O O Feeling queasy; headache over eyes 57. O O O Greasy foods upset 58. O O O Stools light covered 59. O O O Skin peels on foot soles 60. O O O Pain between shoulder blades 61. O O O Use laxatives 62. O O O Stools alternate from soft to watery 63. O O O History of gallbladder attacks or gallstones 64. O O O Dreaming, nightmare type bad dreams 65. O O O Bad breath (halitosis) 66. O O O Milk products cause distress 67. O O O Burning or itching anus Group 6 68. O O O Loss of taste for meat 69. O O O Lower bowel gas several hours after eating 70. O O O Burning stomach sensations, eating relieves 71. O O O Coated tongue 72. O O O Pass large amounts of foul smelling gas 73. O O O Indigestion 1/2-1 hour after eating; may be up to 3-4 hours 74. O O O Mucous colitis or irritable bowel syndrome 75. O O O Stomach bloating after eating Group 7A 76. O O O Insomnia 77. O O O Can t gain weight 78. O O O Intolerance to heat 79. O O O Highly emotional 80. O O O Night sweats 81. O O O Inward trembling, Nervousness 82. O O O Heart palpitations 83. O O O Can t work under pressure Group 7B 84. O O O Increase in weight 85. O O O Decrease in appetite 86. O O O Fatigue easily 87. O O O Ringing in ears 88. O O O Sleepy during day 89. O O O Sensitive to cold 90. O O O Constipation 91. O O O Mental sluggishness 92. O O O Hair coarse, falls out 93. O O O Headaches upon arising, wear off during day 94. O O O Frequency of urination 95. O O O Impaired hearing 96. O O O Reduced initiative Group 7C 97. O O O Failing memory 98. O O O Low blood pressure Group 7D 99. O O O Abnormal thirst 100. O O O Bloating of abdomen 101. O O O Weight gain around hips or waist 102. O O O Sex drive reduced or lacking 103. O O O Tendency to ulcers, colitis 104. O O O Women: menstrual disorders 105. O O O Young girls: lack of menstrual function
Group 7E 106. O O O Hot flashes (female) 107. O O O Increased blood pressure 108. O O O Hair growth on face or body (female) 109. O O O Masculine tendencies (female) Group 7F 110. O O O Chronic fatigue 111. O O O Low blood pressure 112. O O O Nails weak, ridged 113. O O O Tendency to hives 114. O O O Arthritic tendencies 115. O O O Perspiration increase 116. O O O Poor Circulation 117. O O O Swollen ankles 118. O O O Crave salt 119. O O O Brown spots or bronzing of the skin 120. O O O Allergies tendency to asthma 121. O O O Weakness after colds, influenza Group 8 122. O O O Irritability 123. O O O Morbid fears 124. O O O Never seem to get well 125. O O O Forgetfulness 126. O O O Muscular soreness 127. O O O Depression; feelings of dread 128. O O O Noise sensitivity 129. O O O Acoustic hallucinations 130. O O O Tendency to cry without reason 131. O O O Nervousness 132. O O O Insomnia 133. O O O Anxiety 134. O O O Inability to concentrate; confusion 135. O O O Frequent stuffy nose; sinus infections 136. O O O Allergy to some foods 137. O O O Loose joints Allergies Food Allergies: None Yes Explain: Environmental Allergies: None Dust Pollen Ragweed Molds Grass Other: Sleep How many sleep hours do you get? How many do you think you need? Describe how you fall asleep? Watch TV Read a Book Go to Bed Other: Do you have trouble falling asleep? Yes No Sometimes How long does it take you to fall asleep? If you awaken at night, do you have trouble falling back asleep? Yes No Sometimes How long does it take to fall back asleep? What time do you go to bed? What time do you get up? Are your sleep habits routine? Yes No Why not? Do you have trouble waking up in the morning? Yes No Sometimes Do you feel well rested upon awakening? Yes No Sometimes Do you get tired during the day? Yes No Sometimes What times? Do you get a second wind late at night? Yes No Sometimes How often/ week? On a scale 1-10 highest what is your present energy level? 1 2 3 4 5 6 7 8 9 10
Exercise Programs Are you doing any type of exercise? Consistently Yes No Explain: _ Present Weight Weight Weight 1 year ago Weight 5 years ago MAX. Weight as an Adult When Circumstances MIN. Weight as an Adult When Circumstances What do you consider a healthy weight for yourself Number per day? Bowel Movements Number per week? Do you notice a change w/diet? If yes, what change? How many times per week for solid stools? Runny or loose stools? What color? Clay Lt. Brown Med. Brown Dark Brown Black Tan Red Sexual Activity Do you still have pain or discomfort with sexual intercourse? If yes, explain What is the frequency of your present sexual activity? Per Week/Month/Year Do you find your present method satisfactory for your health? Have you ever had a sexually transmitted disease? Yes No If yes, explain Daily Beverages & Food Cravings Water: Daily, in ounces: (by itself) Caffeine Free Beverages: When you have intense cravings, which foods or type of foods do you usually crave? Chocolate Sweets Salty Caffeinated Beverages: Other: Goals: (What do you want to accomplish at Trinity Holistic Wellness). 1. 2. 3. 4. What percent are you committed to getting well? Is there anything you would like to add?
138. O O O Very easily fatigued 139. O O O Premenstrual tension 140. O O O Painful menses 141. O O O Depressed feeling before period 142. O O O Menstruation excessive 143. O O O Painful breasts 144. O O O Menstruate too frequently 145. O O O Hysterectomy/ ovaries removed 146. O O O Menses scanty or missed 147. O O O Acne worse at menses 148. O O O Depression of long standing Menstrual History Age at First Menstrual Period Date Last Menstrual Period How many days from start of one period to start of the next? How many days does (did) your period last? Is (was) your cycle regular? Yes No Not Always Do (did) you pass any clots? Yes Is (was) the flow Heavy Medium Light Age and year of menopause Pre/Peri/Post Menopausal Symptoms Do you have hot flashes/night sweats? Yes No # during day Mild Moderate Severe # during night Mild Moderate Severe Ever taken estrogen or hormone replacements (HRT)? Yes No Name: Dosage: Age and year at time of estrogen/hrt How many years on it Female Only Urogenital Do you get yeast infections? How often? Date of last one? Any increase of urinary frequency or urgency? Yes No Any urinary incontinence? Yes No How Long? UTI s? Yes No If yes, when Blood in urine Yes No Female Reproductive History Have you been treated for infertility? Please indicate what type and duration: 1 Injections: 2 Clomid: 3 IVF: 4 Other : Have you used an IUD? Describe any problems with IUD: Have used any form of Birth Control Pill Patch or Shot? Please indicate how long: 1 Pill: 2 Shot : 3 Patch: 4 Other : Age while on BC Have you ever been pregnant? Number of Pregnancies: 1 2 3 4 5 6 7 8 9 How old were you during pregnancies Describe any complications with pregnancies/deliveries? How much did each child weigh Did you breastfeed? Yes No If so, how long? Number of Miscarriages Number of stillbirths Number of premature births Number of cesarean births Number of abortions