NAME DATE Circle if you: ADDRESS Diet often Do t exercise regularly Salt food without tasting Are under excessive stress Are exposed to chemicals at work Are exposed to cigarette smoke REFERRAL PHONE DATE OF BIRTH Male Female 2 = Moderate Circle any of the following medications you are taking: Antacids Antibiotic/Antifungal Antidepressants Antidiabetic/Insulin Aspirin/Paracetamol Chemotherapy Cortisone/Anti-inflammatory Heart Medications High Blood Pressure Hormones Laxatives Lithium Oral Contraceptives Radiation Recreational Drugs: Relaxants/Sleeping Pills Thyroid Ulcer Medications Other (specify): In the following sections circle or mark the number which best describes your symptoms: 0 = Symptom is t present 1 = Mild 3 = Severe If you do t kw the answer to a question leave it blank. Part 1 Section A 1 Burping 2 Fullness after meals 3 Bloating 4 Stomach upsets easily Part 1 Section B 1 Abdominal cramps 2 Indigestion 1-3 hours after eating Circle if you eat, drink or use: 3 Intestinal gas Alcohol Candy/Sweets Fizzy drinks Cigarettes Coffee 4 Alternating constipation and diarrhoea Distilled water Fast food restaurants regularly Fried Foods 5 Diarrhoea Deli Meats Margarine Refined sugars 6 Roughage and fibre causes constipation Saccharine/Aspartame (Canderel, Splenda etc) Chewing tobacco 7 Mucous in stools Vitamins/Minerals (list) 8 Stool poorly formed 9 Shiny stool 10 3 or more large bowel movements daily
Part 1 Section C Part 2 Section B 1 Burning in stomach 2 Indigestion 1 Swollen eyes (bulging) 3 Acid reflux 2 Palpitations 4 Difficulty belching 3 Insomnia 5 Heartburn 4 Heat intolerance 6 Sudden acute indigestion 7 History of ulcer or gastritis 5 Nervousness 8 Nausea yes (10) Part 2 Section C 1 Cold Intolerance Part 1 Section D 2 Chronic fatigue 3 Depressed, apathetic 1 Hard stools 4 Low sex drive 2 Abdominal cramps or pain in lower abdomen 5 Dry, rough pale skin 3 Bloating or lower bowel gas 6 Muscle cramps and muscle aches 4 Alternating diarrhoea/constipation 7 Constipation 5 Constipation 8 Thinning or loss of outside portion of eyebrow 6 Rectal bleeding 9 Gain weight easily 10 Axillary temperature below 36.5 C 11 Abrmal menstrual cycles Part 2 Section A Part 3 Section A 1 Intolerance to greasy foods 2 Elevated liver enzymes 1 Itchy eyes 3 Light coloured stool 2 Red or inflamed eyes 4 Foul smelling stool 3 Low blood pressure 5 Sour taste in mouth 4 Sensitive to fumes/smoke/smog/chemicals 6 Grey coloured skin 5 Cant tolerate much exercise 7 Yellow in whites of eyes 6 Depression or rapid mood swings 8 Bad breath 7 Dark circles under eyes 9 Body odour 8 Dizziness upon standing 10 Pain in liver area, right side under rib cage 9 Lack of mental alertness 11 Big toe painful 10 Catch colds easily when weather changes 12 Red blood in stool yes (6) 11 Water retention 13 Have had jaundice or hepatitis 12 Eyes sensitive to bright light 13 Feel weak and shaky
Part 3 Section B Part 4 Section B 1 Itching of se or eyes 1 Cold hands and feet 2 Itching of roof of mouth or throat 2 Weakened veins or varicose veins 3 Swollen joints 3 Swollen extremities 4 Food sensitivity or allergy 4 Numbness in extremities 5 Alternating constipation and diarrhoea 5 Poor concentration 6 Watery eyes 6 Ringing in ears 7 Running se 7 Tingling and/or burning in hands and feet 8 Swollen tongue 8 Spider veins on se and/or face 9 Difficulty swallowing 10 Wheezing Part 4 Section C 11 Skin rashes 12 Sneezing (allergic) 1 Pain getting up in morning in back of head 13 Migraine headaches 2 Dizziness 3 Tightness or discomfort in chest Part 3 Section C 4 Nosebleeds 0 5 Is your blood pressure high? 1 Running se (chronic) 6 Swollen extremities 2 Get boils or styes 3 Throat infections Part 5 Section A 4 Cold sores, fever blisters 1 2 3 yes (10) 5 Poor wound healing 1 Dizziness when standing suddenly 6 Joint inflammation and swelling 2 Fainting 7 Swollen lymph glands 3 Crave sweets 8 Ear infections (chronic) 4 Headache relieved by consumption of sweets 9 Slow to recover from cold or flu 5 Feel shaky or jittery 10 Catch colds or flu easily 6 Irritable, tired or weak if meal is missed 7 Wake up in middle of night craving sweets Part 4 Section A 8 Impatient, moody, nervous 9 Feel tired 1-3 hours after eating 1 Chest pain while walking 10 Calmer after eating 2 Heaviness in legs 3 Heart pounds easily 4 Dizziness 5 Heart misses beats or has extra beats 6 Swelling of feet and ankles 7 Rapidly beating heart 8 Pain in left arm 9 Exhaustion with mir exertion 10 Have you been told you have heart trouble? yes (5)
Part 5 Section B Part 7 1 Night sweats (t mepausal hot flashes) 1 Frequent urination 2 Lowered resistance to infection 2 Frequent bladder infections 3 Fatigue (chronic) 3 Urination when you cough or sneeze 4 Deteriorating eyesight 4 Painful/burning when you pass urine 5 Lesions and cuts take a long time to heal 5 Difficulty passing urine 6 Weight gain or inability to lose weight 6 Dripping after urination 7 Numbness in extremities yes (5) 7 Can't hold urine 8 Family history of diabetes yes (5) 8 Rose coloured (bloody) urine 9 Crave sweets, eating sweets does t help 9 Cloudy urine 10 Strong smelling urine 11 Back or leg pains with dripping after urination Part 6 12 Back pain in kidney area 13 General water retention 1 Chest pain 14 History of kidney or bladder infections 2 Chronic cough 15 Often used antibiotics to control urinary infection 3 Difficulty breathing 16 Increased thirst 4 Coughing up blood 5 Coughing up phlegm Part 8 Section A (Males only) 6 Pain around ribs 7 Shortness of breath 1 Difficulty urinating 8 Rattling mucous when you breath 2 A sense of bladder fullness 9 Infections settle in lungs 3 Weak urinary flow 10 Bronchitis yes (10) 4 Blood in semen 11 Exposed to chemicals and radiation yes (6) 5 Pain or burning when urinating 12 Asthma yes (6) 6 Wake up to urinate at night 7 Dripping after urination 8 Urinary tract infections 9 Ejaculation causes pain Part 8 Section B (Males only) 1 Difficult attaining and/or maintaining erection 2 Low sexual drive 3 Premature ejaculation 4 Pain/coldness in genital area 5 Infertile 6 Varicose veins on scrotum 7 Low sperm count 0 1 2 3 yes (5) yes (5)
Part 9 Section A (Females only) Part 10 Section A 1 Abrmal flow (too heavy or light or irregular) 1 Pain in fingers 2 Depression 2 Bones sore/painful 3 Moodiness/irritability 3 Arthritis 4 Bloating and swelling 4 Bone loss 5 Cramps 5 Calcium deposits 6 Headaches (second half of cycle) 6 Bone deformity yes (5) 7 Anger (second half of cycle) 7 You have osteoporosis/ osteomalacia? yes (5) 8 Tender breasts 8 Recent bone fracture 9 Long-term steroid use Part 9 Section B (Females only) 10 Loss of mobility 1 Low abdominal pain 2 Dull ache radiating to low back or legs Part 10 Section B 3 Increased urinary frequency 4 Pelvic soreness 1 Muscle spasm 5 Abdominal bloating 2 Tightness in shoulder muscles 6 Menstrual pain 3 Muscle cramps 7 Have to lie down on first 1 or 2 days of period 4 Pain in arms, hands 8 Light, scanty blood flow 5 Leg cramps at night 9 Pain and cramps without blood flow 6 Stiff all over 10 Heavy menstrual bleeding 7 Stiff in morning 11 Anxiety about menstrual cycle 8 Unable to sit straight 12 Pain during period gets worse with time 9 Pain in neck and/or shoulders 10 Back pain Part 9 Section C (Females only) 11 Atrophy 1 Hot flashes 2 Night sweats Part 10 Section C 3 Depression/mood swings 4 Insomnia 1 Over-flexible joints (double jointed) 5 Heavy bleeding 2 weeks out of the month 2 Tennis elbow 6 Sweating throughout the day 3 Swollen knees/elbows 7 Dryness of skin, hair and vagina 4 Rheumatoid arthritis 8 Painful intercourse 5 Bursitis 9 Vaginal pain/dryness 6 Tendonitis 10 Osteoporosis (bone loss) yes (5) 7 Joint pain 11 Total hysterectomy yes (5) 8 Slipped disk 9 Herniated disk 0 1 2 3 yes (5) 10 Injure easily
Part 11 1 Head feels heavy 2 Light headedness/fainting 3 Loss of balance 4 Dizziness 5 Ringing/buzzing in the ears 6 Trembling hands 7 Loss of feeling in hands and/or feet (toes) 8 Exhaustion on slightest effort 9 Limbs feel heavy to hold up 10 Loss of grip strength 11 Tingling pain sensation 12 Un-coordination 13 Nervousness 14 Convulsions yes (10) 15 Loss of muscle tone 16 Have you had shingles? Part 12 Sleep Patterns 1 Nightmares 2 Can't fall asleep 3 Intense dreams 4 Restless leg at night 5 Restless, uneasy sleeper 6 Awake frequently throughout the night yes (5) 7 Wake up in the night, can't fall back to sleep yes (5) 8 Sleepwalk yes (10)
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