Symptom Survey

Assessment of psychological and physiological symptoms.

Step 1 of 3

MM slash DD slash YYYY
MM slash DD slash YYYY

INSTRUCTIONS: Fill in only the circles which apply to you. Leave blank if you don't have the problem.
* Fill in the circle marked 1 for MILD symptoms (occurred once or twice last 6 months).
* Fill in the circle marked 2 for MODERATE symptoms (occurred once or twice last month).
* Fill in the circle marked 3 for SEVERE symptoms (chronic, occurred once or twice last week)

Leave circles BLANK if they don't apply to you!
Acid foods upset
Get chilled often
"Lump" in throat
Dry mouth-eyes-nose
Pulse speeds after meal
Keyed up - fail to calm
Cut heals slowly
Gag easily
Unable to relax; startles easily
Extremities cold, clammy
Strong light irritates
Urine amount reduced
Heart pounds after retiring
"Nervous" stomach
Appetite reduced
Cold sweats often
Fever easily raised
Neuralgia-like pains
Staring, blinking little
Sour stomach often
Joint stiffness on arising
Muscle-leg-toe cramps at night
"Butterfly" stomach, cramps
Eyes or nose watery
Eyes blink often
Eyelids swollen, puffy
Indigestion soon after meals
Always seems hungry; feels "lightheaded" often
Digestion rapid
Vomiting frequent
Hoarseness frequent
Breathing irregular
Pulse slow; feels "irregular"
Gagging reflex slow
Difficulty swallowing
Constipation, diarrhea alternating
"Slow starter"
Get "chilled" infrequently
Perspire easily
Circulation poor, sensitive to cold
Subject to colds, asthma, bronchitis
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
Crave candy or coffee in afternoons
Moods of depression - "blues" or melancholy
Abnormal craving for sweets or snacks
Hands and feet go to sleep easily, numbness
Sigh frequently, "air hunger"
Aware of "breathing heavily"
High altitude discomfort
Opens windows in closed rooms
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", worse on exertion