System Survey Form

Name*

First NameLast Name

Date*

Date

Phone Number*

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Email*

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Sex At Birth*

MaleFemale

Select the corresponing number

0	Symptom Does Not Apply
1	MILD Symptom (Occurs Rarely)
2	MODERATE Symptom (Occurs Several Times A Month)
3	SEVERE Symptom (Occurs Almost Constantly

Group 1*

	0	1	2	3
Acid Foods Upsets
Gets Chilled Often
"Lump" In Throat
Dry Mouth, Eyes, Nose
Pulse Speeds After Meal
"Keyed Up", Can't Calm Down
Gag Occasionally
Unable To Relax, Startle Easily
Extremities Cold, Clamy
Strong Light Irritates
Occasionally Weak Urine Flow
Heart Pounds After Retiring
"Nervous" Stomach
Appetite Reduced Occasionally
Cold Sweats
Gets Hot Easily
Nerve Discomfort
Staring, Blinking Little
Sour Stomach Frequent

Results Group 1 (Sympathetic)

Group 2*

	0	1	2	3
Joints Stiffness After Arising
Muscle, Leg, Toe Cramps At Night
"Butterfly" Stomach, Cramps
Eyes Or Nose Watery
Eyes Blink Often
Eyes Swollen, Puffy
Indigestion Soon After Meals
Always Seems Hungry, Feel "Lightheaded" Often
Digestion Rapid
Vomit Occasionally
Hoarseness Frequent
Uneven Breathing
Pulse Slow
Gagging reflex Slow
Difficulty Swallowing
Temporary Constipation Or Diarrhea
"Slow Starter"
Gets "Chilled"
Perspires Easily
Sensitive To Cold
Upper Respiratory Challenges

Results Group 2 (Parasympathetic)

Group 3*

	0	1	2	3
Eat When Nervous
Excessive Appetite
Hungry Between Meals
Irritable Before Meals
Gets "Shakey" If Hungry
Eating Relieves Fatigue
"Lightheaded" If Meals Delayed
Heart Palpates If Meals Missed Or Delayed
Fatigue In Afternoon
Overeating Sweets Upsets
Awaken After A Few Hours Sleep, Hard To Get Back To Sleep
Crave Candy Or Coffee In The Afternoon
Moods Of "Blues" Or Melancholy
Cravings For Sweets & Snacks

Results Group 3 (Blood Sugar)

Group 4*

	0	1	2	3
Hands & Feet Go To Sleep Easily, Numbness
Sigh Frequently
Aware Of Breathing Heavy
High-Altitude Discomfort
Open Windows In A closed Room
Immune System Challenges
Afternoon Yawner
Gets Drowsy Often
Swollen Ankles Worse At Night
Muscle Cramps Worse During Exercise; Gets "Charlie Horses"
Difficulty Catching Breath, Especially During Exercise
Tightness Or Pressure In Chest, Worse On Exertion
Skin Discolors Easily After Impact
Tendency To Anemia
Noises In Head Or "Ringing In Ears"
Fatigue Upon Exertion

Results Group 4 (Cardiovascular)

Group 5*

	0	1	2	3
Dizziness
Dry Skin
Burning Feet
Blurred Vision
Itching Skin & Feet
Hair Loss
Occasional Constipation
Worrier, Feels Insecure
Nausea Occasionally After Eating
Greasy Foods Upset
Stools Light-colored
Skin Peels On Foot Soles
Discomfort Between Shoulder Blades
Occasional Laxative Use
Stools Alternate From Soft To Watery
Sneezing Attacks
Nightmares or Bad Dreams
Bad Breath (Halitosis)
Milk Products Cause Upset
Sensitive To Hot Weather
Burning Or Itching Anus
Crave Sweets

Results Group 5 (Liver/Gallbladder)

Group 6*

	0	1	2	3
Loss Of Taste For Meat
Lower Bowel Gas Several Hours After Eating
Burning Stomach Sensation, Eating Relieves
Coated Tongue
Pass Large Amounts Of Foul-Smelling Gas
Indigestion 30 Minutes - 1 Hour (May be 3-4 Hours) After Eating
Watery Or Loose Stool
Gas Shortly After Eating
Stomach Bloating

Results Group 6 (Digestive)

Group 7A*

	0	1	2	3
Difficulty Sleeping
On "Edge"
Can't Gain Weight
Intolerance To Heat
Highly Emotional
Flush Easly
Night Sweats
Thin, Moist Skin
Inward trembling
Heart Races
Increased Appetite Without Weight Gain
Pulse Fast At Rest
Eyelids & Face Twitch
Irritable & Restless
Can't Work Under Pressure

Results Group 7A (Endocrine: Hyperthyroid)

Group 7B*

	0	1	2	3
Increase In Weight
Decrease In Appetite
Fatigue Easily
Ringing In Ears
Sleepy During The Day
Sensitive To Cold
Dry Or Scaly Skin
Temporary Consipation
Mental Sluggishness
Hair Coarse, Falls Out
Tension In Head Upon Arising, Wears Off During The Day
Slow Pulse Below 65
Changing Urinary Function
Sounds Appear Diminished
Reduced Initiative

Results Group 7B (Endocrine: Hypothyroid)

Group 7C*

	0	1	2	3
Failing Memory With Age
Increased Sex Drive
Episodes Of Tension In Head
Decreased Sugar Tolerance

Results Group 7C (Endocrine: Hyperpituitary)

Group 7D*

	0	1	2	3
Abnormal Thirst
Bloating In Abdomen
Weight Gain Around Hips & Waist
Sex Drive Reduced Or Lacking
Tendancy For Stomach Issues
Immune System Challenges
Menstrual Disoder (If Male Select 0)

Results Group 7D (Endocrine: Hypopituitary)

Group 7E*

	0	1	2	3
Dizziness
Headaches
Hot Flashes
Hair Growth On Face Or Body (Males Select 0)
Sugar In Urine (Not Diabetes)
Masculine Tendancies (Males Select 0)

Results Group 7E (Endocrine: Hyperadrenal)

Group 7F*

	0	1	2	3
Weakness, Dizziness
Tired Throughout The Day
Nails Weak Ridged
Sensitive Skin
Stiff Joints
Perspiration increase
Bowel discomfort
Poor Circulation
Swollen Ankles
Crave Salt
Areas Of Skin Darkening
Upper Respiratory Sensitivity
Tiredness
Breathing Challenges

Results Group 7F (Hypoadrenal)

Group 8*

	0	1	2	3
Muscle Weakness
Lack Of Stamina
Drowsiness After Eating
Muscular Soreness
Heart Races
Hyperirritable
Feeling Of A Band Around The Head
Melancholia (Feeling Of Sadness)
Swelling Ankles
Change Of Urinary Function
Tendency To Consume Sweets/Carbohydrates
Muscle Spasm
Blurred Vision
Involuntary Muscle Action
Numbness
Night Sweats
Rapid Digestion
Sensitivity To Noise
Redness Of Palms & Bottom Of Feet
Visible Veins On Chest & Abdomen
Hemorrhoids
Apprehension (Feeling Like Something Bad Is Going To Happen)
Nervousness Causing Loss Of Appetite
Nervousness With Indigestion
Gastritis
Forgetfulness
Thinning Hair

Results Group 8 (B & G Complex)

Female Only

	0	1	2	3
Very Easily Fatigued
Premenstrual Tension
Menses More Painful Than Usual
Depressed Feeling Before Menstruation
Painful Breasts During Menses
Menstruate Too Frequently
Hysterectomy/Ovaries Removed
Menopausal Hot Flashes
Menses Scanty Or Missed
Acne, Worse At Menses

Results Female Only

Male Only

	0	1	2	3
Less Involved In Exercise/Social Activities
Difficult To Postpone Urination
Weak Urinary Stream
Feeling Of "Blues" Or Melancholy
Feeling Of Incomplete Bowel Evacuation
Lack Of Energy
Muscles In Arms & Legs Seem Softer/Smaller
Tire Too Easily
Avoid Activity
Leg Nervousness At Night
Diminished Sex Drive

Results Male Only

Grand total

IMPORTANT: Please List Below The Five Main Physical Complaints You Have In Order
Of Importance

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