Holistic Preventive Clinic

Holistic Preventive Clinic www.holisticpreventive.com Phone: (253) 564-8431 Fax: (253) 584-0414 Email: [email protected]

Symptoms Survey Form

This form is to be sent at least 48 hours prior to your consultation. Should you be unable to provide Holistic Preventive Clinic with required documents within 48 hours of your scheduled appointment, the appointment will be cancelled and you will be charged for the appointment. You will need to purchase another session at the same rate.

Please choose on a scale of 1 – 4 the appropriate answer to each question below (Put “x” with corresponding number next to each question): 1 = Least/Never and 4 = Most/Always

Patient Name

Phone # Email Date

Category I 1 2 3 4 Loss of taste for meat Feeling that bowels do not empty completely Lower abdominal pain reliefs by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Roughage/fiber cause constipation, undigested foods found in stools Hard dry or small stool

Stool undigested, foul smelling mucous‐like, greasy or poorly formed

Coated tongue Pass large amount of foul smelling gas

Stomach pain, burning, aching and fullness 1‐4 hours after eating

Burning stomach pain relief from antacids, food, milk and carbon. Drinks Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine Heartburn when lying down or bending forward Feeling hungry an hour or two after eating and increased thirst Stomach bloating after eating Pain, tenderness, soreness on left side under rib cage Nausea and /or vomiting Difficulty losing weight Digestive problems subside with rest and relaxation Frequent urination Do you use laxatives frequently Do you frequently use antacids Total:

Category II 1 2 3 4 Dry Skin Burning feet Blurred vision Itching skin and feet Excessive falling hair Frequent skin rashes Bitter, metallic taste in mouth in mornings Bowel movements painful or difficult Lower bowel gas and or bloating several hours after eating Feeling nauseous; headache over eyes Greasy foods upset Bad breath Stools light-colored Skin peels on foot soles Pain between shoulder blades Stools alternate from soft to watery Burning or itching anus Yellowish cast to eyes Use laxatives History of gallbladder attacks or stones Have you had your gallbladder removed? Milk products cause distress Sensitive to hot weather Crave sweets Total:

Category III 1 2 3 4 Crave sweets during the day Eat when nervous Excessive appetite Hungry between meals Irritable before meals Get "shaky" if hungry Fatigue, eating relieves Lightheaded if meals delayed Heart palpitates if meals missed or delayed Afternoon headaches Overeating sweets upsets Awaken after few hours sleep - hard to get back to sleep Total:

Category IV 1 2 3 4 Weakness, dizziness Slow starter in the morning Chronic fatigue and afternoon fatigue Low blood pressure Nails weak, ridged Tendency to hives Arthritic tendencies Perspiration increase Bowel disorders Poor circulation Swollen ankles Crave salt Cannot stay asleep Dizziness when standing up quickly Afternoon headaches Brown spots or bronzing of skin Allergies - tendency to asthma Weakness after colds, influenza Exhaustion - muscular and nervous Respiratory disorders Total:

Category V 1 2 3 4 Dizziness Increased blood pressure Headaches Hair growth on face or body (female) Hot flashes Cannot fall asleep Perspire easily Weight gain when under stress Wake up tired even after 6 or more hours of sleep Sugar in urine (not diabetes) Masculine tendencies (female) Total:

Category VI 1 2 3 4 Tired, sluggish Feel cold – hands, feel, all over Require excessive amounts of sleep to function properly Sleepy during day Fatigue easily

Increase in weight gain even with low‐calorie diet

Gain weight easily Constipation Depression, lack of motivation Morning headaches that wear off as the day progresses Outer third of eyebrow thins Thinning of hair on scalp, face or genitals or excessive falling hair Dryness of skin and/or scalp Mental sluggishness Decrease in appetite Ringing in ears Slow pulse, below 65 Frequency of urination Impaired hearing Total:

Category VII 1 2 3 4 Insomnia Nervousness Night sweats Can’t gain weight Thin, moist skin Intolerance to heat Inward trembling Highly emotional Heart palpitates Increased pulse even at rest Eyelids and face twitch Irritable and restless Can’t work under pressure Total:

Category VIII 1 2 3 4 Diminished sex drive Menstrual disorders or lack of menstruation Increased ability to eat sugars without symptoms Abnormal thirst Bloating of abdomen Tendency to ulcers, colitis Weight gain around hips or waist Total:

Category IX 1 2 3 4 Increased sex drive Decreased sugar tolerance “Splitting” type headaches Failing memory Low blood pressure Total:

Category X 1 2 3 4 Hands and feet go to sleep easily, numbness Sigh frequently, "air hunger" Aware of "breathing heavily" High altitude discomfort Opens windows in closed room Susceptible to colds and fevers Afternoon "yawner" Get "drowsy" often Swollen ankles worse at night Muscle cramps, worse during exercise; get "charley horses" Shortness of breath on exertion Dull pain in chest or radiating into left arm, worse on exertion Bruise easily, "black and blue" spots Tendency to anemia Nose bleeds frequent Noises in head, or "ringing in ears" Tension under the breastbone, or feeling of "tightness" Total:

Category XI 1 2 3 4 Irritability, anxiety and nervousness Never seems to get well Forgetfulness, inability to concentrate; confusion Depression; feelings of dread Noise sensitivity Tendency to cry without reason Indigestion Anorexia and poor appetite Craving for sweets Muscular soreness Weakness and fatigue Skin sensitive to touch Headache Insomnia Frequent stuffy nose; sinus infections Total:

Category XII 1 2 3 4 Burning sensations or pain during urination Frequent urination Cloudy and foul-smelling urine Pain directly above the pubic bone Back or pelvic pain Occasionally blood may be visible in the urine Leak urine during activity: exercise, sneezing, coughing, sex Swelling of the legs, ankles, feet, hands and puffiness around the eyes (fluid retention) High blood pressure Fatigue and weakness Loss of appetite, nausea, vomiting and a metallic taste in the mouth Itching, easy bruising, skin rashes and pale skin Shortness of breath from fluid accumulation in the lungs Total:

Category XIII 1 2 3 4 Tender, warm, swollen joints especially in the hands or feet Morning stiffness that may last for hours The pain eases the more people use the joint Joint aching and soreness, especially with movement Pain after overuse or after long periods of inactivity Stiffness after periods of rest The same joint affected on both sides of the body Pain that can last through the night Firm bumps of tissue under the skin on your arms Fever because their immune system is in overdrive Fatigue and weight loss Trouble sleeping Weakness and loss of mobility Depression Cramps, muscle aches, and bone pain Height loss Spinal fractures Low overall fitness Decreased grip strength Receding gums Total:

Category XIV 1 2 3 4 Alternating menstrual cycle lengths Extended menstrual cycle, greater than 32 days Shortened menses, less than every 24 days Pain and cramping during periods Light blood flow Heavy blood flow Breast pain and swelling during menses Pelvic pain during menses Irritable and depressed during menses Vaginal discharge Acne break outs Total:

Category XV 1 2 3 4 Do you ever have uterine bleeding since menopause Hot Flashes Mental Fogginess Disinterest in Sex Mood Swings Depression Painful intercourse Shrinking breast Facial hair growth Acne Increased vaginal pain, dryness or itching Total:

Category XVI 1 2 3 4 Urination difficulty or dribbling Urination frequent Pain inside of legs or heels Feeling of incomplete bowel evacuation Leg nervousness at night Decrease in libido Decrease in fullness of erections Spells of mental fatigue Inability to concentrate Episodes of depression Muscle soreness Decrease in physical stamina Unexplained weight gain Increase in fat distribution around chest and hips Sweating attacks More emotional than in the past Total