Systems Survey Form - Date: 2025/04/04

GROUP 1

1 2 3 | Acid foods upset

1 2 3 | Get chilled often

1 2 3 | “Lump” in throat

1 2 3 Dry mouth, eyes, nose

1 2 3 Pulse speeds after meal

1 2 3 Keyed up, fail to calm

1 2 3 Gag occasionally

1 2 3 Unable to relax, startle easily

1 2 3 Extremities cold, clammy

1 2 3 Strong light irritates

1 2 3 Occasionally weak urine flow

1 2 3 Heart pounds after retiring

1 2 3 “Nervous” stomach

1 2 3 Appetite reduced occasionally

1 2 3 Cold sweats often

1 2 3 Get heated easily

1 2 3 Nerve discomfort

1 2 3 Staring, blink little

1 2 3 Sour stomach frequent

GROUP 2

1 2 3 | Joint stiffness after arising

1 2 3 | Muscle, leg, toe cramps at night

1 2 3 | “Butterfly” stomach, cramps

1 2 3 | Eyes or nose watery

1 2 3 | Eyes blink often

1 2 3 | Eyelids swollen, puffy

1 2 3 | Indigestion soon after meals

1 2 3 | Always seem hungry, feel “lightheaded” often

1 2 3 | Digestion rapid

1 2 3 | Vomit occasionally

1 2 3 | Hoarseness frequent

1 2 3 | Uneven breathing

1 2 3 | Pulse slow

1 2 3 | Gagging reflex slow

1 2 3 | Difficulty swallowing

1 2 3 | Temporary constipation or diarrhea

1 2 3 | “Slow starter”

1 2 3 | Get “chilled”

1 2 3 | Perspire easily

1 2 3 | Sensitive to cold

1 2 3 | Upper respiratory challenges

Group 3

1 2 3 | Eat when nervous

1 2 3 | Excessive appetite

1 2 3 | Hungry between meals

1 2 3 | Irritable before meals

1 2 3 | Get “shaky” if hungry

1 2 3 | Fatigue, eating relieves

1 2 3 | “Lightheaded” if meals delayed

1 2 3 | Heart palpitates if meals missed or delayed

1 2 3 | Fatigue in afternoon

1 2 3 | Overeating sweets upsets

1 2 3 | Awaken after few hours sleep, hard to get back to sleep

1 2 3 | Crave candy or coffee in afternoon

1 2 3 | Moods of “blues” or melancholy

1 2 3 | Craving for sweets or snacks

GROUP 4

1 2 3 | Hands and feet go to sleep easily, numbness

1 2 3 | Sigh frequently, "air hunger"

1 2 3 | Aware of "breathing heavily"

1 2 3 | High-altitude discomfort

1 2 3 | Open windows in closed room

1 2 3 | Immune system challenges

1 2 3 | Afternoon "yawner"

1 2 3 | Get "drowsy" often

1 2 3 | Swollen ankles worse at night

1 2 3 | Muscle cramps, worse during exercise; get "charley horse"

1 2 3 | Difficulty catching breath, especially during exercise

1 2 3 | Tightness or pressure in chest, worse on exertion

1 2 3 | Skin discolors easily after impact

1 2 3 | Tendency to anemia

1 2 3 | Noises in head or "ringing in ears"

1 2 3 | Fatigue upon exertion

GROUP 5

1 2 3 | Dizziness

1 2 3 | Dry skin

1 2 3 | Burning feet

1 2 3 | Blurred vision

1 2 3 | Itching skin and feet

1 2 3 | Hair loss

1 2 3 | Occasional skin rashes

1 2 3 | Bitter, metallic taste in mouth in morning

1 2 3 | Occasional constipation

1 2 3 | Worrier, feels insecure

1 2 3 | Nausea occasionally after eating

1 2 3 | Greasy foods upset

1 2 3 | Stools light-colored

1 2 3 | Skin peels on foot soles

1 2 3 | Discomfort between shoulder blades

1 2 3 | Occasional laxative use

1 2 3 | Stools alternate from soft to watery

1 2 3 | Sneezing attacks

1 2 3 | Dreaming, nightmare-type bad dreams

1 2 3 | Bad breath (halitosis)

1 2 3 | Milk products cause upset

1 2 3 | Sensitive to hot weather

1 2 3 | Burning or itching anus

1 2 3 | Crave sweets

GROUP 6

1 2 3 | Loss of taste for meat

1 2 3 | Lower bowel gas several hours after eating

1 2 3 | Burning stomach sensations, eating relieves

1 2 3 | Coated tongue

1 2 3 | Pass large amounts of foul-smelling gas

1 2 3 | Indigestion 1/2-1 hour after eating; may be up to 3-4 hours after

1 2 3 | Watery or loose stool

1 2 3 | Gas shortly after eating

1 2 3 | Stomach "bloating"

GROUP 7A

1 2 3 | Difficulty sleeping

1 2 3 | On edge

1 2 3 | Can't gain weight

1 2 3 | Intolerance to heat

1 2 3 | Highly emotional

1 2 3 | Flush easily

1 2 3 | Night sweats

1 2 3 | Thin, moist skin

1 2 3 | Inward trembling

1 2 3 | Heart races

1 2 3 | Increased appetite without weight gain

1 2 3 | Pulse fast at rest

1 2 3 | Eyelids and face twitch

1 2 3 | Irritable and restless

1 2 3 | Can't work under pressure

GROUP 7B

1 2 3 | Increase in weight

1 2 3 | Decrease in appetite

1 2 3 | Fatigue easily

1 2 3 | Ringing in ears

1 2 3 | Sleepy during day

1 2 3 | Sensitive to cold

1 2 3 | Dry or scaly skin

1 2 3 | Temporary constipation

1 2 3 | Mental sluggishness

1 2 3 | Hair coarse, falls out

1 2 3 | Tension in head upon arising, wears off during day

1 2 3 | Slow pulse below 65

1 2 3 | Changing urinary function

1 2 3 | Sounds appear diminished

1 2 3 | Reduced initiative

GROUP 7C

1 2 3 | Failing memory with age

1 2 3 | Increased sex drive

1 2 3 | Episodes of tension in head

1 2 3 | Decreased sugar tolerance

GROUP 7D

1 2 3 | Abnormal thirst

1 2 3 | Bloating of abdomen

1 2 3 | Weight gain around hips or waist

1 2 3 | Sex drive reduced or lacking

1 2 3 | Tendency for stomach issues

1 2 3 | Immune system challenges

1 2 3 | Menstrual disorders

GROUP 7E

1 2 3 | Dizziness

1 2 3 | Headaches

1 2 3 | Hot flashes

1 2 3 | Hair growth on face or body (female)

1 2 3 | Sugar in urine (not diabetes)

1 2 3 | Masculine tendencies (female)

GROUP 7F

1 2 3 | Weakness, dizziness

1 2 3 | Tired throughout day

1 2 3 | Nails weak, ridged

1 2 3 | Sensitive skin

1 2 3 | Stiff joints

1 2 3 | Perspiration increase

1 2 3 | Bowel discomfort

1 2 3 | Poor circulation

1 2 3 | Swollen ankles

1 2 3 | Crave salt

1 2 3 | Areas of skin darkening

1 2 3 | Upper respiratory sensitivity

1 2 3 | Tiredness

1 2 3 | Breathing challenges

GROUP 8

1 2 3 | Muscle weakness

1 2 3 | Lack of stamina

1 2 3 | Drowsiness after eating

1 2 3 | Muscular soreness

1 2 3 | Heart races

1 2 3 | Hyperirritable

1 2 3 | Feeling of a band around head

1 2 3 | Melancholia (feeling of sadness)

1 2 3 | Swelling of ankles

1 2 3 | Change in urinary function

1 2 3 | Tendency to consume sweets/carbohydrates

1 2 3 | Muscle spasms

1 2 3 | Blurred vision

1 2 3 | Involuntary muscle action

1 2 3 | Numbness

1 2 3 | Night sweats

1 2 3 | Rapid digestion

1 2 3 | Sensitivity to noise

1 2 3 | Redness of palms of hands and bottom of feet

1 2 3 | Visible veins on chest and abdomen

1 2 3 | Hemorrhoids

1 2 3 | Apprehension (feeling that something bad is going to happen)

1 2 3 | Nervousness causing loss of appetite

1 2 3 | Nervousness with indigestion

1 2 3 | Gastritis

1 2 3 | Forgetfulness

1 2 3 | Thinning hair

GROUP FEMALE ONLY

1 2 3 | Very easily fatigued

1 2 3 | Premenstrual tension

1 2 3 | Menses more painful than usual

1 2 3 | Depressed feelings before menstruation

1 2 3 | Painful breasts during menses

1 2 3 | Menstruate too frequently

1 2 3 | Hysterectomy/ovaries removed

1 2 3 | Menopausal hot flashes

1 2 3 | Menses scanty or missed

1 2 3 | Acne, worse at menses

GROUP MALE ONLY

1 2 3 | Less involved in exercise/social activities

1 2 3 | Difficult to postpone urination

1 2 3 | Weak urinary stream

1 2 3 | Feeling of "blues" or melancholy

1 2 3 | Feeling of incomplete bowel evacuation

1 2 3 | Lack of energy

1 2 3 | Muscles in arms and legs seem softer/smaller

1 2 3 | Tire too easily

1 2 3 | Avoid activity

1 2 3 | Leg nervousness at night

1 2 3 | Diminished sex drive

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IMPORTANT | Please list below the five main physical complaints you have in order of their importance

Complaint 1:

Complaint 2:

Complaint 3:

Complaint 4:

Complaint 5:

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