Online Patient Form

Patient Name: *

First Name Mid Initial Last Name

Birthday:

Date

Sex:

Male Female

Approximate Weight:

Doctor:

Vegetarian:

Yes No

Gallbladder Removed:

Pulse:

Recumbent:

Standing:

Blood Pressure:

Recumbent:

Standing:

INSTRUCTIONS: Fill in only the circles which apply to you. Leave circles blank if they don’t apply to you! Some questions will repeat.

1 - Mild, 2 - Moderate, 3 - Severe

	1	2	3

1 is , 3 is MILD symptoms (occurs infrequently)

	1	2	3

1 is , 3 is MODERATE symptoms (occurs frequently)

	1	2	3

1 is , 3 is SEVERE symptoms (chronic, always present)

	1	2	3

1 is , 3 is Leave circles BLANK if they do not apply to you!

--------------------------------------------- GROUP 01 ---------------------------------------------

Type a question

	1	2	3

1 is 1. , 3 is Acid foods upset

Type a question

	1	2	3

1 is 2. , 3 is Get chilled often

Type a question

	1	2	3

1 is 3. , 3 is “Lump” in throat

Type a question

	1	2	3

1 is 4. , 3 is Dry mouth-eyes-nose

Type a question

	1	2	3

1 is 5. , 3 is Pulse speeds after meal

Type a question

	1	2	3

1 is 6. , 3 is Keyed up - fail to calm

Type a question

	1	2	3

1 is 7., 3 is Cut heals slowly

Type a question

	1	2	3

1 is 8., 3 is Gag easily

Type a question

	1	2	3

1 is 9., 3 is Unable to relax; startles easily

Type a question

	1	2	3

1 is 10., 3 is Extremities cold, clammy

Type a question

	1	2	3

1 is 11. , 3 is Strong light irritates

Type a question

	1	2	3

1 is 12. , 3 is Urine amount reduced

Type a question

	1	2	3

1 is 13. , 3 is Heart pounds after retiring

Type a question

	1	2	3

1 is 14. , 3 is Heart pounds after retiring

Type a question

	1	2	3

1 is 15. , 3 is Appetite reduced

Type a question

	1	2	3

1 is 16. , 3 is Cold sweats often

Type a question

	1	2	3

1 is 17. , 3 is Fever easily raised

Type a question

	1	2	3

1 is 18. , 3 is Neuralgia-like pains

Type a question

	1	2	3

1 is 19. , 3 is Staring, blinks little

Type a question

	1	2	3

1 is 20. , 3 is Sour stomach often

--------------------------------------------- GROUP 02 ---------------------------------------------

	1	2	3

1 is 21., 3 is Joint stiffness on arising

	1	2	3

1 is 22., 3 is Muscle-leg-toe cramps at night

	1	2	3

1 is 23., 3 is “Butterfly” stomach, cramps

	1	2	3

1 is 24., 3 is Eyes or nose water

	1	2	3

1 is 25., 3 is Eyes blink often

	1	2	3

1 is 26., 3 is Eyelids swollen, puffy

	1	2	3

1 is 27., 3 is Indigestion soon after meals

	1	2	3

1 is 28., 3 is Always seems hungry; feels “lightheaded” often

	1	2	3

1 is 29., 3 is Digestion rapid

	1	2	3

1 is 30., 3 is Vomiting frequent

	1	2	3

1 is 31., 3 is Hoarsenss frequent

	1	2	3

1 is 32., 3 is Breathing irregular

	1	2	3

1 is 33., 3 is Pulse slow; feels “irregular”

	1	2	3

1 is 34., 3 is Gagging reflex slow

	1	2	3

1 is 35., 3 is Difficulty swallowing

	1	2	3

1 is 36., 3 is Constipation, diarrhea alternating

	1	2	3

1 is 37., 3 is “Slow starter”

	1	2	3

1 is 38., 3 is Get “chilled” infrequently

	1	2	3

1 is 39., 3 is Perspire easily

	1	2	3

1 is 40., 3 is Circulation poor, sensitive to cold

	1	2	3

1 is 41., 3 is Subject to colds, asthma, bronchitis

	1	2	3

1 is 37., 3 is “Slow starter”

--------------------------------------------- GROUP 03 ---------------------------------------------

	1	2	3

1 is 42., 3 is Eat when nervous

	1	2	3

1 is 43, 3 is Excessive appetite

	1	2	3

1 is 44., 3 is Hungry between meals

	1	2	3

1 is 45, 3 is Irritable before meals

	1	2	3

1 is 46, 3 is Get “shaky” before meals

	1	2	3

1 is 47, 3 is Fatigue, eating relieves

	1	2	3

1 is 48, 3 is “Lightheaded” if meals delayed

	1	2	3

1 is 49., 3 is Heart palpitates if meals missed or delayed

	1	2	3

1 is 50., 3 is Afternoon headaches

	1	2	3

1 is 51., 3 is Overeating sweets upsets

	1	2	3

1 is 52., 3 is Awaken after few hours sleep - hard to go back to sleep

	1	2	3

1 is 53., 3 is Crave candy or coffee in afternoons

	1	2	3

1 is 54., 3 is Moods of depression - “blues” or melancholy

	1	2	3

1 is 55., 3 is Abnormal craving for sweets or snacks

--------------------------------------------- GROUP 04 ---------------------------------------------

	1	2	3

1 is 56., 3 is Hands and feet go to sleep easily, numbness

	1	2	3

1 is 57., 3 is Sigh frequently, “air hunger”

	1	2	3

1 is 58., 3 is Aware of “breathing heavily”

	1	2	3

1 is 59., 3 is High altitude discomfort

	1	2	3

1 is 60., 3 is Opens windows in closed rooms

	1	2	3

1 is 61., 3 is Susceptible to colds and fevers

	1	2	3

1 is 62., 3 is Afternoon “yawner”

	1	2	3

1 is 63., 3 is Get “drowsy” often

	1	2	3

1 is 64., 3 is Swollen ankles, worse at night

	1	2	3

1 is 65., 3 is Muscle cramps, worse during excercise: get “charley horses”

	1	2	3

1 is 66., 3 is Shortness of breath on exertion

	1	2	3

1 is 67., 3 is Dull pain in chest or radiating into left arm, worse on exertion

	1	2	3

1 is 68., 3 is Bruise easily, “black and blue” spots

	1	2	3

1 is 69., 3 is Tendency to anemia

	1	2	3

1 is 70., 3 is “Nose bleeds” frequent

	1	2	3

1 is 71., 3 is Noises in head, or “ringing in ears”

	1	2	3

1 is 72., 3 is Tension under the breastbone, or feeling of “tightness”, worse on exertion

--------------------------------------------- GROUP 05 ---------------------------------------------

	1	2	3

1 is 73., 3 is Dizziness

	1	2	3

1 is 74., 3 is Dry skin

	1	2	3

1 is 75., 3 is Burning feet

	1	2	3

1 is 76., 3 is Blurred vision

	1	2	3

1 is 77., 3 is Itching skin and feet

	1	2	3

1 is 78., 3 is Excessive falling hair

	1	2	3

1 is 79., 3 is Frequent skin rashes

	1	2	3

1 is 80., 3 is Bitter, metallic taste in mouth in mornings

	1	2	3

1 is 81., 3 is Bowel movements painful or difficult

	1	2	3

1 is 82., 3 is Worrier, feels insecure

	1	2	3

1 is 83., 3 is Feeling queasy; headache over eyes

	1	2	3

1 is 84., 3 is Greasy foods upset

	1	2	3

1 is 85., 3 is Stools light colored

	1	2	3

1 is 86., 3 is Skin peels on foot soles

	1	2	3

1 is 87., 3 is Pain between shoulder blades

	1	2	3

1 is 88., 3 is Use laxatives

	1	2	3

1 is 89., 3 is Stools alternate from soft to watery

	1	2	3

1 is 90., 3 is History of gallbladder attacks or gallstones

	1	2	3

1 is 91., 3 is Sneezing attacks

	1	2	3

1 is 92., 3 is Dreaming, nightmare type bad dreams

	1	2	3

1 is 93., 3 is Bad breath (halitosis)

	1	2	3

1 is 94., 3 is Milk products cause distress

	1	2	3

1 is 95., 3 is Sensitive to hot weather

	1	2	3

1 is 96., 3 is Burning or itching anus

	1	2	3

1 is 97., 3 is Crave sweets

--------------------------------------------- GROUP 06 ---------------------------------------------

	1	2	3

1 is 98., 3 is Loss of taste for meat

	1	2	3

1 is 99., 3 is Lower bowel gas several hours after eating

	1	2	3

1 is 100., 3 is Burning stomach sensations, eating relieves

	1	2	3

1 is 101., 3 is Coated tongue

	1	2	3

1 is 102., 3 is Pass large amounts of foul-smelling gas

	1	2	3

1 is 103., 3 is Indigestion 1/2-1 hour after eating; may be up to 3-4 hours

	1	2	3

1 is 104., 3 is Mucous colitis or irritable bowel

	1	2	3

1 is 105., 3 is Gas shortly after eating

	1	2	3

1 is 106., 3 is Stomach “bloating” after eating

--------------------------------------------- GROUP 07A---------------------------------------------

	1	2	3

1 is 107., 3 is Insomnia

	1	2	3

1 is 108., 3 is Nervousness

	1	2	3

1 is 109., 3 is Can’t gain weight

	1	2	3

1 is 110., 3 is Intolerance to heat

	1	2	3

1 is 111., 3 is Highly emotional

	1	2	3

1 is 112., 3 is Flush easily

	1	2	3

1 is 113., 3 is Night sweats

	1	2	3

1 is 114., 3 is Thin, moist skin

	1	2	3

1 is 115., 3 is Inward trembling

	1	2	3

1 is 116., 3 is Heart palpitates

	1	2	3

1 is 117., 3 is Increased appetite without weight gain

	1	2	3

1 is 118., 3 is Pulse fast at rest

	1	2	3

1 is 119., 3 is Eyelids and face twitch

	1	2	3

1 is 120., 3 is Irritable and restless

	1	2	3

1 is 121., 3 is Can’t work under pressure

--------------------------------------------- GROUP 07B---------------------------------------------

	1	2	3

1 is 122., 3 is Increase in weight

	1	2	3

1 is 123., 3 is Decrease in appetite

	1	2	3

1 is 124., 3 is Fatigue easily

	1	2	3

1 is 125., 3 is Ringing in ears

	1	2	3

1 is 126., 3 is Sleepy during day

	1	2	3

1 is 127., 3 is Sensitive to cold

	1	2	3

1 is 128., 3 is Dry or scaly skin

	1	2	3

1 is 129., 3 is Constipation

	1	2	3

1 is 130., 3 is Mental sluggishness

	1	2	3

1 is 131., 3 is Hair coarse, falls out

	1	2	3

1 is 132., 3 is Headaches upon arising, wear off during day

	1	2	3

1 is 133., 3 is Slow pulse, below 65

	1	2	3

1 is 134., 3 is Frequency of urination

	1	2	3

1 is 135., 3 is Impaired hearing

	1	2	3

1 is 136., 3 is Reduced initiative

--------------------------------------------- GROUP 07C---------------------------------------------

	1	2	3

1 is 137., 3 is Failing memory

	1	2	3

1 is 138., 3 is Low blood pressure

	1	2	3

1 is 139., 3 is Increased sex drive

	1	2	3

1 is 140., 3 is Headaches, “splitting or rending” type

	1	2	3

1 is 141., 3 is Decreased sugar tolerance

--------------------------------------------- GROUP 07D---------------------------------------------

	1	2	3

1 is 142., 3 is Abnormal thirst

	1	2	3

1 is 143., 3 is Bloating of abdomen

	1	2	3

1 is 144., 3 is Weight gain around hips or waist

	1	2	3

1 is 145., 3 is Sex drive reduced or lacking

	1	2	3

1 is 146., 3 is Tendency to ulcers, colitis

	1	2	3

1 is 147., 3 is Increased sugar tolerance

	1	2	3

1 is 148., 3 is Women: menstrual disorders

	1	2	3

1 is 149., 3 is Young girls: lack of menstrual function

--------------------------------------------- GROUP 07E---------------------------------------------

	1	2	3

1 is 150., 3 is Dizziness

	1	2	3

1 is 151., 3 is Headaches

	1	2	3

1 is 152., 3 is Hot flashes

	1	2	3

1 is 153., 3 is Increased blood pressure

	1	2	3

1 is 154., 3 is Hair growth on face or body (female)

	1	2	3

1 is 155., 3 is Sugar in urine (not diabetes)

	1	2	3

1 is 156., 3 is Masculine tendencies (female)

--------------------------------------------- GROUP 07F---------------------------------------------

	1	2	3

1 is 157., 3 is Weakness, dizziness

	1	2	3

1 is 158., 3 is Chronic fatigue

	1	2	3

1 is 159., 3 is Low blood pressure

	1	2	3

1 is 160., 3 is Nails weak, ridged

	1	2	3

1 is 161., 3 is Tendency to hives

	1	2	3

1 is 162., 3 is Arthritic tendencies

	1	2	3

1 is 163., 3 is Perspiration increased

	1	2	3

1 is 164., 3 is Bowel disorders

	1	2	3

1 is 165., 3 is Poor circulation

	1	2	3

1 is 166., 3 is Swollen ankles

	1	2	3

1 is 167., 3 is Crave salt

	1	2	3

1 is 168., 3 is Brown spots or bronzing of skin

	1	2	3

1 is 169., 3 is Allergies - tendency to asthma

	1	2	3

1 is 170., 3 is Weakness after colds, influenza

	1	2	3

1 is 171., 3 is Exhaustion - muscular and nervous

	1	2	3

1 is 172., 3 is Respiratory disorders

--------------------------------------------- GROUP 08---------------------------------------------

	1	2	3

1 is 173., 3 is Apprehension

	1	2	3

1 is 174., 3 is Irritability

	1	2	3

1 is 175., 3 is Morbid fears

	1	2	3

1 is 176., 3 is Never seems to get well

	1	2	3

1 is 177., 3 is Forgetfulness

	1	2	3

1 is 178., 3 is Indigestion

	1	2	3

1 is 179., 3 is Poor appetite

	1	2	3

1 is 180., 3 is Craving for sweets

	1	2	3

1 is 181., 3 is Muscular soreness

	1	2	3

1 is 182., 3 is Depression: feelings of dread

	1	2	3

1 is 183., 3 is Noise sensitivity

	1	2	3

1 is 184., 3 is Acoustic hallucination

	1	2	3

1 is 185., 3 is Tendency to cry without reason

	1	2	3

1 is 186., 3 is Hair is coarse and/or thinning

	1	2	3

1 is 187., 3 is Weakness

	1	2	3

1 is 188., 3 is Fatigue

	1	2	3

1 is 189., 3 is Skin sensitive to touch

	1	2	3

1 is 190., 3 is Tendency toward hives

	1	2	3

1 is 191., 3 is Nervousness

	1	2	3

1 is 192., 3 is Headache

	1	2	3

1 is 193., 3 is Insomnia

	1	2	3

1 is 194., 3 is Anxiety

	1	2	3

1 is 195., 3 is Anorexia

	1	2	3

1 is 196., 3 is Inability to concentrate; confusion

	1	2	3

1 is 197., 3 is Frequent stuffy nose; sinus infections

	1	2	3

1 is 198., 3 is Allergy to some foods

	1	2	3

1 is 199., 3 is Loose joints

--------------------------------------------- FEMALE ONLY-------------------------------------

	1	2	3

1 is 200., 3 is Very easily fatigued

	1	2	3

1 is 201., 3 is Premenstrual tension

	1	2	3

1 is 202., 3 is Painful menses

	1	2	3

1 is 203., 3 is Depressed feelings before menstruation

	1	2	3

1 is 204., 3 is Menstruation excessive and prolonged

	1	2	3

1 is 205., 3 is Painful breasts

	1	2	3

1 is 206., 3 is Menstruate too frequently

	1	2	3

1 is 207., 3 is Vaginal discharge

	1	2	3

1 is 208., 3 is Hysterectomy / ovaries removed

	1	2	3

1 is 209., 3 is Menopausal hot flashes

	1	2	3

1 is 210., 3 is Menses scanty or missed

	1	2	3

1 is 211., 3 is Acne, worse at menses

	1	2	3

1 is 212., 3 is Depression of long standing

--------------------------------------------- MALE ONLY-------------------------------------

	1	2	3

1 is 213., 3 is Prostate trouble

	1	2	3

1 is 214., 3 is Urination difficult or dribbling

	1	2	3

1 is 215., 3 is Night urination frequent

	1	2	3

1 is 216., 3 is Depression

	1	2	3

1 is 217., 3 is Pain on inside of legs or heels

	1	2	3

1 is 218., 3 is Feeling of incomplete bowel evacuation

	1	2	3

1 is 219., 3 is Lack of energy

	1	2	3

1 is 220., 3 is Migrating aches and pains

	1	2	3

1 is 221., 3 is Tire too easily

	1	2	3

1 is 222., 3 is Avoids activity

	1	2	3

1 is 223., 3 is Leg nervousness at night

	1	2	3

1 is 224., 3 is Diminished sex drive

IMPORTANT: List the five main complaints you have in the order of their importance.

1.

2.

3.

4.

5.

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