Symptom Survey - Purchase 21 day body detox diet for colon cleansing and healthy weight loss

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Symptom Survey

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Age:
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Sex:	Male Female
History of Illness and Treatment:
Surgeries, Accidents or Injuries:
Present Illness or Complaints:
Diagnostic Summary
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Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click "not an issue"
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Instructions:

Not An Issue – if a symptom does not apply to you, click “not an issue.’
1 for MILD symptoms (occurs rarely)
2 for MODERATE symptoms (occurs several times a month)
3 for SEVERE symptoms (occurs almost constantly)

Main Physical Complaints
1.
2.
3.
4.
5.

GROUP ONE
		1	2	3	Not An Issue
1.	Acid food upsets
2.	Get chilled, often
3.	“Lump” in throat
4.	Dry mouth-eyes-nose
5.	Pulse speeds after meals
6.	Keyed up - fail to calm
7.	Cuts heal slowly
8.	Gag easily
9.	Unable to relax, startles easily
10.	Extremities cold, 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.	Fever easily raised
18.	Neuralgia-like pains
19.	Staring, blinks little
20.	Sour stomach frequent

GROUP TWO
		1	2	3	Not An Issue
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, puffy
27.	Indigestion soon after meals
28.	Always seem hungry; feels lightheaded often
29.	Digestion rapid
30.	Vomiting frequent
31.	Hoarseness frequent
32.	Breathing Irregular
33.	Pulse slow; feels “irregular”
34.	Gagging reflex slow
35.	Difficulty swallowing
36.	Constipation, diarrhea alternating
37.	“Slow Starter”
38.	Get “chilled” infrequently
39.	Perspire easily
40.	Circulation poor, sensitive to cold
41.	Subject to colds, asthma, bronchitis

GROUP THREE
		1	2	3	Not An Issue
42.	Eat when nervous
43.	Excessive appetite
44.	Hungry between meals
45.	Irritable before meals
46.	Get “shaky” if hungry
47.	Fatigue, eating relieves
48.	“Lightheaded” if meals delayed
49.	Heart palpitates if meals missed or delayed
50.	Afternoon headaches
51.	Overeating sweet upsets
52.	Awaken after 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

GROUP FOUR
		1	2	3	Not An Issue
56.	Hands and feet go to sleep easily, numbness
57.	Sigh frequently, “air hunger”
58.	Aware of “breathing heavily”
59.	High altitude discomfort
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: get “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 and blue” spots
69.	Tendency to anemia
70.	“Nose bleeds” frequent
71.	Noises in head, or “ringing in ears”
72.	Tension under the breastbone, or feeling of “tightness”, worse on exertion

GROUP FIVE
		1	2	3	Not An Issue
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, metallic taste in mouth in mornings
81.	Bowel movements painful or difficult
82.	Worrier, feels insecure
83.	Feeling queasy, headache over eyes
84.	Greasy food upset
85.	Stools light-colored
86.	Skin peels on foot soles
87.	Pain between shoulder blades
88.	Use laxatives
89.	Stools alternate from soft to watery
90.	History of gallbladder attacks or gallstones
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

GROUP SIX
		1	2	3	Not An Issue
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 ½ - 1 hour after eating; may be up to 3-4 hours
104.	Mucous colitis or “irritable bowel”
105.	Gas shortly after eating
106.	Stomach “bloating” after eating

GROUP SEVEN
		1	2	3	Not An Issue
107.	Insomnia
108.	Nervousness
109.	Can’t gain weight
110.	Intolerance to heat
111.	Highly emotional
112.	Flush easily
113.	Night sweats
114.	Thin, moist skin
115.	Inward trembling
116.	Heart palpitates
117.	Increased appetite without weight gain
118.	Pulse fast at rest
119.	Eyelids and face twitch
120.	Irritable and restless
121.	Can’t work under pressure
122.	Increase in weight
123.	Decrease in appetite
124.	Fatigue easily
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.	Frequency of urination
135.	Impaired hearing
136.	Reduced initiative
137.	Failing memory
138.	Low blood pressure
139.	Increased sex drive
140.	Headaches, “splitting or rendering” type
141.	Decreased sugar tolerance
142.	Abnormal thirst
143.	Bloating of abdomen
144.	Weight gain around hips or waist
145.	Sex drive reduced or lacking
146.	Tendency to ulcers, colitis
147.	Increased sugar tolerance
148.	Women: menstrual disorders
149.	Young girls: lack of menstrual function
150.	Dizziness
151.	Headaches
152.	Hot flashes
153.	Increased blood pressure
154.	Hair growth on face or body (female)
155.	Sugar in urine (not diabetes)
156.	Masculine tendencies (female)
157.	Weakness, dizziness
158.	Chronic fatigue
159.	Low blood pressure
160.	Nails, weak, ridged
161.	Tendency to hives
162.	Arthritic tendencies
163.	Perspiration increase
164.	Bowel disorders
165.	Poor circulation
166.	Swollen ankles
167.	Crave salt
168.	Brown spot or bronzing of skin
169.	Allergies – tendency to asthma
170.	Weakness after colds, influenza
171.	Exhaustion – muscular and nervous
172.	Respiratory disorders

GROUP EIGHT
		1	2	3	Not An Issue
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.	Depressions: 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

FEMALE ONLY
		1	2	3	Not An Issue
200.	Very easily fatigued
201.	Premenstrual tension
202.	Painful menses
203.	Depressed feeling before menstruation
204.	Menstruation excessive and prolonged
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.	Depression of long standing

MALE ONLY
		1	2	3	Not An Issue
213.	Prostate trouble
214.	Urination difficult or dribbling
215.	Night urination frequent
216.	Depression
217.	Pain on inside of leg or heels
218.	Feeling incomplete bowel evacuation
219.	Lack of energy
220.	Migrating aches and pains
221.	Tire too easily
222.	Avoids activity
223.	Leg nervousness at night
224.	Diminished sex drive