Healing Light Holistic Center Symptom Survey

Healing Light Holistic Center

Symptom Survey Online Form

For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

Name
Phone       e-mail
Address      City
State      Zip
Birthday:    Month    Day    Year
SEX:   Male        Female
HEIGHT:      WEIGHT:

Do you have any known allergies? If so, to what?

INSTRUCTIONS: Check one of the 4 circles: 1-does not apply , 2-mild, 3-moderate, 4-severe

This Symptom Survey has 212 questions, Please be aware that it will take some time to fill this survey out in it's entirety.

	NA	1	2	3
					Does Not Apply ( selected as shown if the symptom does not apply to you)
					MILD symptoms (once or twice last 6 month)
					MODERATE symptoms (once or twice last month)
					SEVERE symptoms (Chronic, once or twice last wk)

	NA	1	2	3	GROUP 1 SYMPATHETIC DOMINANCE
1					Acid foods upset
2					Feel chilled often
3					"Lump" in throat
4					Dry mouth-eyes-nose
5					Pulse speeds after meals
6					Keyed up; unable to feel calm
7					Cuts heal slowly
8					Gag easily
9					Unable to relax; startles easily
10					Extremities cold and/or clammy
11					Strong light irritates
12					Urine amount reduced
13					Heart pounds after retiring
14					^"Nervous" stomach
15					Appetite reduced
16					Cold sweats often
17					Body temperature rises easily
18					Skin sensitive to touch
19					Staring, blinks little
20					Frequently have a sour stomach

	NA	1	2	3	GROUP 2 PARASYMPATHETIC DOMINANCE
21					Joint stiffness after arising
22					Muscle-leg-toe cramps at night
23					"Butterfly" stomach, cramps
24					Eyes or nose watery
25					Eyes blink often
26					Eyelids swollen or puffy
27					Indigestion soon after meals
28					Always seem hungry; 'lightheaded' often
29					Food digests rapidly
30					Vomit frequently
31					Frequently hoarse
32					Irregular breathing
33					Pulse slow or feels ^"irregular"
34					Slow gag reflex
35					Difficulty swallowing
36					Alternating constipation and diarrhea
37					"Slow starter"
38					Not easily chilled
39					Perspire easily
40					Poor circulation or sensitive to cold
41					Subject to colds, asthma, bronchitis

	NA	1	2	3	GROUP 3 SUGAR HANDLING
42					Eat when nervous
43					Excessive appetite
44					Hungry between meals
45					Irritable before meals
46					Get "shaky" if hungry
47					Feeling fatigued, eating relieves
48					"Lightheaded" if meals delayed
49					Heart palpitates if meals missed or delayed
50					Afternoon headaches
51					Upset feeling from excessive eating of sweets
52					Awaken after a few hours sleep, hard to get back to sleep
53					Crave candy or coffee in afternoons
54					Moods of depression, "blues", or melancholy
55					Abnormal craving for sweets or snacks

	NA	1	2	3	GROUP 4 CARDIOVASCULAR
56					Hands and feet go to sleep easily, numbness
57					Sigh frequently, "air hunger"
58					Aware of "breathing heavily"
59					Discomfort at high altitude
60					Opens windows in closed room
61					Susceptible to colds and fevers
62					Afternoon "yawner"
63					Get "drowsy" often
64					Swollen ankles worse at night
65					Muscle cramps, worse during exercise; "charley-horses"
66					Shortness of breath on exertion
67					Dull pain in chest or radiating into left arm, worse on exertion
68					Bruise easily, "black/blue" spots on arms or legs
69					Tendency to anemia
70					Frequently have "nose bleeds"
71					"Ringing in ears" or noises in head
72					Tension under the breast-bone, or feeling of "tightness" in the chest, gets worse on exertion

	NA	1	2	3	GROUP 5 LIVER/BILIARY
73					Dizziness
74					Dry skin
75					Burning feet
76					Blurred vision
77					Itching skin and feet
78					Excessive falling hair
79					Frequent skin rashes
80					Bitter or metallic taste in mouth in the mornings
81					Bowel movements painful or difficult
82					Feelings of worry, dread, or insecurity
83					Feeling queasy; headache over eyes
84					Greasy foods upset
85					Stools light-colored
86					Skin peels on foot soles
87					Pain between shoulder blades
88					Using laxatives
89					Stools alternate from soft to watery
90					History of gallbladder attacks or gall stones
91					Sneezing attacks
92					Dreaming, nightmare-type bad dreams
93					Bad breath (halitosis)
94					Milk products cause distress
95					Sensitive to hot weather
96					Burning or itching anus
97					Crave sweets

	NA	1	2	3	GROUP 6 DIGESTION
98					Loss of taste for meat
99					Lower bowel gas several hours after eating
100					Burning stomach sensations, eating relieves
101					Coated tongue
102					Pass large amounts of foul smelling gas
103					Indigestion 1/2 -1 hour after eating; may be up to 3-4 hrs.
104					Mucus colitis or "irritable bowel"
105					Gas shortly after eating
106					Stomach "bloating" after eating

	NA	1	2	3
					Does Not Apply ( leave it blank or selected as shown if the symptom does not apply to you)
					MILD symptoms (once or twice last 6 month)
					MODERATE symptoms (once or twice last month)
					SEVERE symptoms (Chronic, once or twice last wk)

	NA	1	2	3	GROUP 7A HYPERTHYROID
107					Insomnia
108					Nervousness
109					Can't gain weight
110					Intolerance to heat
111					Highly emotional
112					Flush easily
113					Night sweats
114					Skin is thin and moist
115					Inward trembling
116					Heart palpitates
117					Increased appetite without weight gain
118					Pulse races when resting
119					Eyelids and face twitch
120					Irritable and restless
121					Can't work under pressure

	NA	1	2	3	GROUP 7B HYPOTHYROID
122					Noticeable weight gain
123					Decrease in appetite
124					Easily fatigued
125					Ringing in ears
126					Sleepy during day
127					Sensitive to cold
128					Dry or scaly skin
129					Constipation
130					Mental sluggishness
131					Hair coarse, falls out
132					Headaches upon arising wear off during day
133					Slow pulse, below 65
134					Frequent urination
135					Impaired hearing
136					Reduced initiative

	NA	1	2	3	GROUP 7C HYPERPITUITARY
137					Failing memory
138					Low blood pressure
139					Increased sex drive
140					Headaches, "splitting or rendering" type
141					Decreased sugar tolerance

	NA	1	2	3	GROUP 7D HYPOPITUITARY
142					Abnormal thirst
143					Bloating of the abdomen
144					Weight gain around hips or waist
145					Sex drive reduced or lacking
146					Tendency toward ulcers and/or colitis
147					Increased sugar tolerance
148					(FEMALE) Menstrual disorders
149					(YOUNG GIRLS) Lack of menstrual function

	NA	1	2	3	GROUP 7E HYPERADRENAL
150					Dizziness
151					Headaches
152					Hot flashes
153					Increased blood pressure
154					(FEMALE) Hair growth on face or body
155					Sugar in urine (not diabetes)
156					(FEMALE) Masculine tendencies

	NA	1	2	3	GROUP 7F HYPOADRENAL
157					Weakness and/or dizziness
158					Chronic fatigue
159					Low blood pressure
160					Nails weak and/or ridged
161					Tendency toward hives
162					Arthritic tendencies
163					Perspiration increase
164					Bowel disorders
165					Poor circulation
166					Swollen ankles
167					Crave salt
168					Brown spots or bronzing of skin
169					Allergies - tendency to asthma
170					Weakness after colds or influenza
171					Muscular and nervous exhaustion
172					Respiratory disorders

	NA	1	2	3	GROUP 8 FOUNDATIONAL ISSUES
173					Apprehension
174					Irritability
175					Morbid fears
176					Never seems to get well
177					Forgetfulness
178					Indigestion
179					Poor appetite
180					Craving for sweets
181					Muscular soreness
182					Depression; feelings of dread
183					Noise sensitivity
184					Acoustic hallucinations
185					Tendency to cry without reason
186					Hair is coarse and/or thinning
187					Weakness
188					Fatigue
189					Skin sensitive to touch
190					Tendency toward hives
191					Nervousness
192					Headache
193					Insomnia
194					Anxiety
195					Anorexia
196					Inability to concentrate; confusion
197					Frequent stuffy nose; sinus infections
198					Allergy to some foods
199					Loose joints

	NA	1	2	3	FEMALE ONLY
200					Very easily fatigued
201					Premenstrual tension
202					Painful menses
203					Depressed feelings before menstruation
204					Excessive and prolonged menstruation
205					Painful breasts
206					Menstruate too frequently
207					Vaginal discharge
208					Hysterectomy / ovaries removed
209					Menopausal hot flashes
210					Menses scanty or missed
211					Acne, worse at menses
212					Long standing depression

	NA	1	2	3	MALE ONLY
213					Prostate trouble
214					Urination difficult or dribbling
215					Frequent night time urination
216					Depression
217					Pain on inside of legs or heels
218					Feeling of incomplete bowel evacuation
219					Lack of energy
220					Migrating aches and pains
221					Too easily tired
222					Avoids activity
223					Leg nervousness at night
224					Diminished sex drive

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Notes:

Clicking on the submit button will e-mail a copy of your Symptom Survey to Healing Light Holistic Center.