Health
Survey
Name:
___________________________________________
Birth
Date _________________
Constitution
________________
Circle the answer that best reflects
the intensity of each symptom at this time
0 = never 1 = seldom 2 = occasional 3 = often
Unit
I: DIGESTION
Part
A: LOW ACIDITY
1.
Indigestion 0 1 2 3
2.
Abdominal bloating 0 1 2 3
3.
Feel too full after eating 0 1 2 3
4.
Constipation 0 1 2 3
5.
Belching / Burping 0 1 2 3
6.
Diminished appetite 0 1 2 3
7.
Stomach growls / gurgles 0 1 2 3
8.
Any known food allergies? N Y
Part
B: HIGH ACIDITY
1.
Stomach pains just before or after meals 0 1 2 3
2.
Stomach pains with no apparent reason 0 1 2 3
3.
Stomach pain relieved by carbonated drinks
0 1 2 3
4.
Stomach pain relieved by milk / cream 0 1 2 3
5.
Emotional upset causes stomach pain 0 1 2 3
6.
Heartburn immediately after meals 0 1 2 3
7.
Constant need for antacids 0 1 2 3
8.
"Butterfly feeling" in stomach 0 1 2 3
9.
Family history of ulcer / gastritis? N Y
10.
Ulcer in the past year? N
Y
11.
Current ulcer? N
Y
12.
Very dark or black stool? N
Y
13.
Hot / spicy food cause stomach irritation? N
Y
Unit
II: ASSIMILATION
Part
A: SMALL INTESTINE 0 1 2 3
1.
Stomach cramps 0 1 2 3
2.
Indigestion immediately after eating 0 1 2 3
3.
Feel tired after meals 0 1 2 3
4.
Flatulence (gas) 0 1 2 3
5.
Constipation / diarrhea (alternating) 0 1 2 3
6.
Fiber rich diet won't stop constipation 0 1 2 3
7.
Loose stool 0 1 2 3
8.
Presence of mucus in stool 0 1 2 3
9.
Stool poorly formed 0 1 2 3
10.
Four or more large stools daily 0 1 2 3
11.
Stools have foul odor 0 1 2 3
12.
Pain in left side of abdomen 0 1 2 3
13.
History of pimples, skin eruptions? N Y
14.
Any known food allergies? N Y
Part
B: LARGE INTESTINE (
1.
Diarrhea 0 1 2 3
2.
Recurrent infections / colds 0 1 2 3
3.
History of kidney and / or bladder infection 0 1 2 3
4.
Yeast infection (including vaginal) 0 1 2 3
5.
Frequent abdominal cramps 0 1 2 3
6.
Fingernail and/or toenail fungus 0 1 2 3
7.
Diarrhea and constipation (alternating) 0 1 2 3
8.
Chronic constipation 0 1 2 3
9.
Use of antibiotics in the past year? N Y
10.
Meat eater? N Y
11.
Vision deteriorating rapidly? N
Y
Unit
III: PANCREAS
Part
A: LOW BLOOD SUGAR (HYPOGLYCEMIA)
1.
Decreased resistance to infection 0 1 2 3
2.
Strong desire / craving for sweets 0 1 2 3
3.
Sweets / alcohol promptly relieve headaches 0 1 2 3
4.
Irritable if a meal is delayed or missed 0 1 2 3
5.
Hungry most of the time 0 1 2 3
6.
Constantly anxious, nervous, worrisome 0 1 2 3
7.
Frequently drowsy, impatient, moody 0 1 2 3
8.
Need for caffeine to get going. 0 1 2 3
Unit III, Part A
(Cont.)
9.
Rapid heart beat after eating sweets 0 1 2 3
10.
Hungry 1-3 hours after eating 0 1 2 3
11.
Restless, poor concentration 0 1 2 3
12.
Forgetful; poor memory 0 1 2 3
13.
Feel shaky; weak or fatigued 0 1 2 3
14.
Feel better / calmer after eating? N Y
15.
Low protein / high carbohydrate diet? N Y
SECTION
B: HIGH BLOOD SUGAR (DIABETES)
1.
Decreased resistance to infection 0 1 2 3
2.
Slow healing cuts, wounds, etc. 0 1 2 3
3.
Night sweats 0 1 2 3
4.
Heightened thirst 0 1 2 3
5.
Increased appetite 0 1 2 3
6.
Eating sweets does not alleviate cravings 0 1 2 3
7.
Fatigue, mental confusion 0 1 2 3
8.
Poor, deteriorating eyesight 0 1 2 3
9.
Itchy skin, boils and / or leg sores 0 1 2 3
10.
History of diabetes in family? N Y
11.
Sugar (glucose) detected in urine? N Y
12.
Low protein / high carbohydrate diet? N
Y
13.
Overweight? N Y
Unit
IV: LIVER
Part
A: LIVER AND GALLBLADDER
1.
Abdominal pain after eating fatty foods 0 1 2 3
2.
Pain in the side under right rib cage 0 1 2 3
3.
Painful or tender big toe 0 1 2 3
4.
Hard / dry stool (painful to pass) 0 1 2 3
5.
Stool color is grayish (light in color) 0 1 2 3
6.
Stool has foul odor 0 1 2 3
7.
Less than one daily bowel movement 0 1 2 3
8.
History of constipation 0 1 2 3
9.
Headaches following meals 0 1 2 3
10.
Recurring sour, bitter taste in mouth 0 1 2 3
11.
Gray colored skin 0 1 2 3
12.
Yellow sclera (white of the eyes) 0 1 2 3
13.
Bad breath or body odor 0 1 2 3
14.
Tired / sleepy after meals 0 1 2 3
15.
Dandruff 0 1 2 3
16.
Retain water 0 1 2 3
17.
Dry skin and/or hair 0 1 2 3
18.
Eat at fast food restaurants 0 1 2 3
19.
Impatient, impulsive, easy to anger 0 1 2 3
20.
Vision problems / red or dry eyes? N Y
21.
Red blood in stool? N Y
22.
Have had jaundice or hepatitis? N Y
23.
High blood cholesterol and / or low HDL cholesterol? N Y
Unit V: URINARY SYSTEM
Part
A: KIDNEY / BLADDER
1.
Constant feeling of a full bladder 0 1 2 3
2.
Loss of control holding urine 0 1 2 3
3.
Drip / Dribble after urination 0 1 2 3
4.
Blood or pus in urine (in any amount) 0 1 2 3
5.
Hazy or cloudy urine 0 1 2 3
6.
Urine has odor / strong smell 0 1 2 3
7.
Long intervals between urination 0 1 2 3
8.
Straining to urinate with scant passage 0 1 2 3
9.
Awaken in middle of night to urinate 0 1 2 3
10.
Feeling of fear / insecurity 0 1 2 3
11.
Dark circles under eyes 0 1 2 3
12.
Pain or pressure in middle of back 0 1 2 3
13.
Intermitent pain in urethra 0 1 2 3
14.
History of bladder infection / cystitis? N Y
15.
Recent use of antibiotics for kidney / bladder infections? N Y
16.
Recent bladder surgery (including A& P repair) N
Y
Unit
VI: THYROID
Part
A: THYROID
1.
Sensitivity to cold / wet weather 0 1 2 3
2.
Hands and feet are cold 0 1 2 3
3.
Constantly tired / fatigued 0 1 2 3
4.
Lack of stamina for daily chores 0 1 2 3
5.
Diagnosis of attention deficit disorder (ADD) 0 1 2 3
6.
Eyes appear bulging or swollen 0 1 2 3
7.
Skin is dry (lacks moisture) 0 1 2 3
8.
Difficulty waking up in the morning 0 1 2 3
9.
Depressed, apathetic, lethargic 0 1 2 3
10.
Lack of or diminished sex drive 0 1 2 3
11.
Irritability / mood swings from eating sweets 0 1 2 3
12.
Constipation 0 1 2 3
13.
Gain weight easily? N Y
14.
Basal (armpit) temperature less than normal? N Y
15.
Slow reflexes /reaction time? N Y
16.
Infertility / impotency? N
Y
For women:
17.
Heavy / profuse menstrual bleeding 0 1 2 3
18.
Premenstrual tension / distress 0 1 2 3
Unit
VII: ADRENAL
Part
A: ADRENAL
1.
Unable to tolerate much exercise 0 1 2 3
2.
Catch colds or get sick easily 0 1 2 3
3.
Sensitive to air pollutants, chemicals, smoke 0 1 2 3
4.
Breathing is labored / difficult 0 1 2 3
5.
Feelings of weakness / shakiness 0 1 2 3
6.
Moments of depression 0 1 2 3
7.
Rapid mood swings 0 1 2 3
8.
Energy lag in morning to mid-afternoon 0 1 2 3
9.
Need for caffeine to get going 0 1 2 3
10.
Intermittent constipation 0 1 2 3
11.
Dark circles beneath the eyes 0 1 2 3
12.
Dizzy / light headed upon standing 0 1 2 3
13.
Lack of mental alertness (mental fog) 0 1 2 3
14.
Retain water 0 1 2 3
15.
Insomnia 0 1 2 3
16.
Eyes sensitive to bright / direct light 0 1 2 3
17.
use cortisone, prednisone, steroids N Y
Unit
VIII: FEMALE
Part
A: SYMPTOMS DURING MENSTRUATION
1.
Monthly weight gain 0 1 2 3
2.
Feelings of depression / anxiety 0 1 2 3
3.
Moodiness / irritability / anger 0 1 2 3
4.
Bloating / swelling 0 1 2 3
5.
Nausea / vomiting 0 1 2 3
6.
Leg cramps / tenderness 0 1 2 3
7.
Headaches 0 1 2 3
8.
Easily distracted 0 1 2 3
9.
Tenderness in breast area 0 1 2 3
10.
Lower back ache 0 1 2 3
11.
Asthma / bronchitis attacks? 0 1 2 3
12.
Suicidal feelings? N Y
Part
B: AMENORRHEA (ABSENCE OF MENSTRUATION)
1.
Vaginal itching / discharge 0 1 2 3
2.
Missed periods 0 1 2 3
3.
Crave sweets or additional food 0 1 2 3
4.
More than 1 cycle per month 0 1 2 3
5.
Low or no desire for sex? N
Y
6.
Pain during intercourse? N Y
7.
Menstruation started after age 15? N Y
8.
Unable to get pregnant? N Y
9.
Number of miscarriages (if any) 0 1 2 3+
10.
Number of abortions (if any) 0 1 2 3+
Part
C: DYSMENORRHEA (PAINFUL MENSTRUATION)
1.
Anxiety about arrival of menstrual cycle 0 1 2 3
2.
Low abdominal pain 0 1 2 3
3.
Dull pain radiating to lower back or legs 0 1 2 3
4.
Menstrual pain 0 1 2 3