Symptom Survey Form

Symptom Survey Form

Fill out this form once a month to monitor your progress and for visits with Dr. Brown.
Date

MonthDayYear
Today's Date
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
CURRENT HEALTH CONCERNS

What is going on?
DESCRIBE YOUR HEALTH - If you could erase 3 problems, what would they be? Example: Great, Good, Poor: 1. Fatigue 2. Sleep issues 3. Constipation
List the 5 major issue you are experiencing.
SUPPLEMENTS AND MEDICATION LIST

What ate you taking?
LIST NUTRITIONAL or MEDICAL SUPPLEMENTATION (Vitamins/Minerals/Herbs/Homeopathic/Pharmcuticals)
List all supplements you are currently taking.
List Medication (Prescribed or over the counter and what they are used for.)
List all pharmaceuticals drugs you are currently taking.
LIFE STYLE PREFERENCES
NUTRITIONAL: Do you currently follow a specific diet or nutritional program? Check all dietary habits that apply to you?

Low fatHigh fatLow simple carbohydratesHigh simple carbohydratesHigh proteinLow proteinNo wheatGluten restrictedNo dairyVegetarianVeganLots of good vegetablesOther
NUTRITIONAL: How are you eating? Do you crave any foods?

SweetsChocolateSaltySourBreadsFattySpicyAlcoholCaffeineOther
NUTRITIONAL: How much water do you drink in a day?

1/2 quart (2 cups:)1 quart (4 cups:)1-1/12 quarts (6 cups:)2 plus quarts (8 cups:)Other
SLEEP SECTION: How are you sleeping? Do you have problems with Sleep or insomnia?

YesNoOther
SLEEP:Do you wake up Refreshed in the morning?

YesNoMost of the TimeOther
PHYSCIAL SURVEY - WHAT ARE YOU SEEING?
You will look at your face and body parts to answer these questions. Look into the mirror for your face, eyes, and tongue.
SYMPTOM SURVEY -

What are you currently Feeling?
INSTRUCTIONS: Fill out each section by CHECKING the circle if your symptoms apply.

Check either MILD, MODERATE, or SEVERE regarding what you feel. Do not check any box if it does not relate to you.

Each section relates to different ORGAN SYSTEMS and provides a big picture of your overall system.

(once a section is clicked, it cannot be set back to zero.)

GROUP 1 - (Sympathetic ANS) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Get chilled often
“Lump” in throat
Pulse speeds after meals
Keyed up – fail to calm down
Cuts heal slowly
Gag easily
Urine amount reduced
Heart pounds after retiring
“Nervous” stomach
Appetite reduced
Cold sweats often
Fever easily raised
Sour stomach often
Skin sensitive to touch

GROUP 2 - (Parasympathetic ANS) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Joint stiffness on arising
Muscle-leg-toe cramps at night
“Butterfly” stomach, cramps
Eyes blink often
Eyes or nose watery
Eyelids swollen, puffy
Indigestion soon after eating
Always hungry; “lightheaded” often
Digestion rapid
Vomiting frequent
Hoarseness frequent
Breathing irregular
Pulse slow; feels “irregular”
Gagging reflex slow
Difficulty swallowing
Constipation, diarrhea alternation
‘Slow starter’
Gets ‘chilled’ infrequently
Perspire easily
Circulation poor, sensitive to cold
Subject to colds, asthma, bronchitis

GROUP 3 - (Blood Sugar) INSTRUCTIONS: CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get ‘shaky’ if hungry
Fatigue, eating relieves
’Lightheaded’ if meals delayed
Heart palpated if meals delayed
Overeating sweets upsets
Awaken few hours’ sleep – hard to get back to sleep
Craves candy or coffee in afternoon
Moods of depression – ‘blues’
Abnormal craving for sweets or snacks

GROUP 4 (Cardiovascular) - INSTRUCTIONS: CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Hands and feet go to sleep easily
Sigh frequently, ‘air under’
High altitude discomfort
Opens windows in closed rooms
Susceptible to colds and fevers
Afternoon ‘yawner’
Get “Drowsy” often
Shortness of breath on exertion
Dull pain in chest, worse on exertion
Nose bleeds’ frequently
Noises in head, or ‘ringing in ears’
Tension/tightness under breastbone

GROUP 5 - (Liver & Gallbladder) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Dizziness
Dry skin
Burning Feet
Itching skin and feet
Frequent skin rashes
Bitter, metallic taste in mouth in morning
Bowel movement painful or difficult
Worrier feels insecure
Headache over eyes
Greasy food upset
Stools light colored
Skin peels on foot soles
Pain between shoulder blades
Use laxatives
Stools alternating from soft to watery
History of gallbladder attach or gallstones
Dreaming, nightmares type bad dreams
Bad breath (halitosis)
Milk products causes distress
Sensitivity to hot water
Burning or itching anus
Craves sweets

GROUP 6 - (Digestion) INSTRUCTIONS: CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Flatulence/Gas after eating
Foul-smelling gas
Stomach ‘Bloated’ after eating
Burning sensation, better eating
Lower Abdominal gas –
Constipation alternating Diarrhea
“Gurgle” Feeling in Abdomen
Queasiness/Nausea/Vomiting
Burping or Belching
Upper Abdominal Pain
Constipation, not having a bowel movement a day
Diarrhea, explosive
Esophageal Reflex
Low back pain/disk
Right-sided hip pain (comes and goes, reoccurring)
Left-sided hip pain (comes and goes, reoccurring)
Tongue coated white
Tongue coated yellow

GROUP 7A - (Hyperthyroid Symptoms) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Insomnia
Nervousness
Can’t gain weight
Intolerance to heat
Highly emotional
Flushes easily
Night sweats
Thin, moist skin
Inward trembling
Heart palpitates
Increased appetite without weight gain
Pulse fast at rest
Eyelids and face twitch

GROUP 7B - (Hypothyroid Symptoms) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Increased weight gain
Decreased in appetite
Fatigue easily
Ringing in ears
Sleepy during the day
Dry or scaly skin
Dry or scaly skin
Constipation
Mental sluggishness
Hair course falls out
Headaches upon arising, wear off during the day
Slow pulse, below 55
Frequency of urination
Reduced initiative
Finger nails brittle
Elbow pain

GROUP 7C - (Pituitary Symptoms) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Failing memory
Low blood pressure
Increased sex drive
Headaches, ‘splitting or rending’ type
Decreased sugar tolerance

GROUP 7D - (Pituitary Symptoms) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Abnormal thirst
Bloating of abdomen
Weight gain around hips or waist
Sex drive reduced or lacking
Tendency to ulcers, colitis
Increased sugar tolerance
Women: menstrual disorder
Young girls: lack of menstrual function

GROUP 7E - (Adrenal Symptoms)CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Dizziness
Headaches
Hot flashes
Increased blood pressure
Hair growth on face and body (female)
Sugar in urine (not diabetes)
Masculine tendencies (female)

GROUP 7F - (Adrenal Symptoms)CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Weakness, dizziness
Chronic fatigue
Low blood pressure
Nails weak, ridged
Tendency to hives
Arthritis tendencies
Perspiration increases
Bowel disorder
Poor circulation
Swollen ankles
Craves salt
Brown spots or bronzing of skin
Allergies – tendency to asthma
Weakness after colds, influenza
Exhaustion – muscular and nervous
Respiratory disorders
Dizziness upon standing
Knee pain

GROUP 8 - (B Vitamin Symptoms) CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Apprehension
Irritability
Morbid fears
Never seems to get well
Forgetfulness
Craving for sweets
Depression, feeling of dread
Noise sensitivity
Acoustic hallucinations
Poor appetite
Tendency to cry without reason
Hair is course and/or thinning
Weakness
Skin sensitive to touch
Tendency towards hives
Nervousness
Headaches
Insomnia
Anxiety
Inability to concentrate, confusion
Frequent stuffy nose, sinus infection
Loose joints
Tongue has cracks or crack down center

(FEMALE ONLY) - CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Polycystic ovaries
Menopausal hot flashes
Very easily fatigue
Premenstrual tension
Painful menses
Depressed feeling before menstruation
Menstruation excessive and prolonged
Menstruate too frequently
Menstruation scanty or missed
Vaginal discharge
Vaginal dryness
Vaginal smell
Hysterectomy/ovaries removed
Menopausal hot flashes
Painful breasts
Acne, worse at menses
Depression of long standing

(MALE ONLY) - CHECK only the boxes which apply to you.

	MILD symptoms (occurred once or twice last 6 month)	MODERATE symptoms (occurred once or twice last month)	SEVERE symptoms (chronic, occurs weekly)
Lack of sex drive
Thumb pain
Prostate problems
Urination difficult or dribbling or Night urination
Night urination frequent
Depression
Pain on inside of legs or heels
Feeling of incomplete bowel evacuation
Lack of energy
Migration aches and pains
Tire easily
Avoids activity
Legs nervousness at night
Diminished sex drive
Erectile dysfunction

Please provide any additional information that you would like to share.
Dr. Keri Brown

719-423-0306 - admin@drkeribrown.com
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CURRENT HEALTH CONCERNS

SUPPLEMENTS AND MEDICATION LIST

LIFE STYLE PREFERENCES

PHYSCIAL SURVEY - WHAT ARE YOU SEEING?

SYMPTOM SURVEY -

Dr. Keri Brown