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
5.
Menstrual pain becoming progressively worse 0 1 2 3
6.
Pain and cramps without blood flow 0 1 2 3
7.
Light, sparse blood flow 0 1 2 3
8.
Heavy menstrual bleeding 0 1 2 3
9.
Nausea / vomiting prior to or during periods
0 1 2 3
10.
Need to lie down first 1 or 2 days of period 0 1 2 3
11.
Increased urinary frequency 0 1 2 3
12.
Pelvic soreness 0 1 2 3
13.
Diarrhea associated with menstruation? N Y
14.
Headache during periods 0 1 2 3
15.
Abdominal bloating 0 1 2 3
16.
Craving for sweets (especially chocolate) 0 1 2 3
Part
D: FIBROUS TISSUE AND CYSTS
1.
Irregularities / soreness / lumps in vaginal area 0 1 2 3
2.
Pain in ovaries 0 1 2 3
3.
Retain water 0 1 2 3
4.
Swollen feeling 0 1 2 3
5.
Premenstrual breast pain or discomfort 0 1 2 3
6.
Breast lumps? N Y
7.
Recent abnormal pap smear? N Y
8.
Family history of breast cancer? N Y
9.
Ovarian / uterine cyst? N Y
10.
Recent use of hormones? N Y
11.
Recent use of birth control device / medication? N
Y
Part
E: CHANGE OF LIFE (AGE 35 AND OVER)
1.
Sweating throughout the day 0 1 2 3
2.
Night sweats 0 1 2 3
3.
Hot flashes 0 1 2 3
4.
Mood swings 0 1 2 3
5.
Insomnia / light sleeper 0 1 2 3
6.
Craving for sweets (especially chocolate) 0 1 2 3
7.
Heavy bleeding two weeks at a time 0 1 2 3
8.
Dryness of pubic hair and vaginal area 0 1 2 3
9.
Vaginal pain / itching 0 1 2 3
10.
Painful intercourse 0 1 2 3
11.
Hysterectomy? N Y
12.
Osteoporosis? N Y
Unit
IX: MALE
Part
A: PROSTATE
1.
Weakened urinary flow 0 1 2 3
2.
Burning / painful urination 0 1 2 3
3.
Bladder feels full 0 1 2 3
4.
Blood / pus in urine (any amount) 0 1 2 3
5.
Awakening to urinate during the night 0 1 2 3
6.
Drip / Dribble after urination 0 1 2 3
7.
Fatigue in legs or lower back 0 1 2 3
8.
Decreased libido / sex drive 0 1 2 3
9.
Pain or discomfort upon ejaculation 0 1 2 3
Part
B: MALE REPRODUCTION
1.
Coldness / pain in genital area 0 1 2 3
2.
Difficulty in maintaining an erection 0 1 2 3
3.
Fear / anxiety about sexual intimacy 0 1 2 3
4.
Premature ejaculation 0 1 2 3
5.
Weak knees / lower back 0 1 2 3
6.
Infertility? N Y
7.
Varicose veins on scrotum? N
Y
8.
Sperm count low? N
Y
9.
Lack of / diminished sex drive? N Y
Part
C: GENITAL INFECTION
1.
Genitals swollen and/or tender 0 1 2 3
2.
Groin area swollen / inflamed 0 1 2 3
3.
Multiple sexual partners 0 1 2 3
4.
Discharge from penis? N Y
5.
Rash on penis / pubic area? N Y
6.
Current venereal disease? N Y
7.
Venereal disease in the past? N Y
Unit
X: CARDIOVASCULAR SYSTEM
Part
A: HEART
1.
Nervous / jittery for no apparent reason 0 1 2 3
2.
Calf muscles cramp when walking 0 1 2 3
3.
Arrhythmia / chest pain when walking 0 1 2 3
4.
Shortness of breath during minor activity 0 1 2 3
5.
Rapid heart beat during minor activity 0 1 2 3
6.
Palpitations / erratic heart beat 0 1 2 3
7.
Numbness / pain in left arm 0 1 2 3
8.
Heaviness in legs 0 1 2 3
9.
Edema/swelling of feet and ankles0 1 2 3
10.
Regular exercise? 0 1 2 3
11.
Frequent aerobic exercise? N Y
12.
Red, swollen nose? N Y
13.
Usual heart beat Slow Normal Fast
Part
B: CIRCULATION
1.
Get angry / excited easily 0 1 2 3
2.
Headaches / migraines for no apparent reason 0 1 2 3
3.
Poor concentration / foggy brain 0 1 2 3
4.
Ringing in ears 0 1 2 3
5.
Cold extremities (hands / feet) 0 1 2 3
6.
Numbness in extremities (hands / feet) 0 1 2 3
7.
Blushing for no apparent reason 0 1 2 3
8.
Speech slurred / sloppy 0 1 2 3
9.
Calf muscles cramp when walking 0 1 2 3
10.
Poor circulation 0 1 2 3
11.
Systolic and diastolic pressures widely separated? N
Y
12.
Lower ear lobe has vertical crease? N Y
13.
Heart attack? N
Y
14. History of stroke? N
Y
15.
Resting blood pressure Low Normal
High
Part
C: HIGH BLOOD PRESSURE
1.
Pain in back of head upon arising in the AM 0 1 2 3
2.
Dizziness / Lightheadedness / vertigo 0 1 2 3
3.
Rapid pulse / shortness of breath 0 1 2 3
4.
Easily tired with minor exertion 0 1 2 3
5.
Visual disturbance 0 1 2 3
6.
Exercise regularly? N Y
7.
Blood pressure higher than it should be? N Y
8.
Systolic and diastolic pressures close to each other? N
Y
Part
D: LYMPHATIC
1.
Need to clear throat, particularly in AM 0 1 2 3
2.
Swelling in throat/neck area 0 1 2 3
3.
Skin irritation / rash 0 1 2 3
4.
Pressure/congestion in or behind ears 0 1 2 3
5.
Do you exercise regularly? N Y
For women:
6.
Nodules or tenderness in breasts 0 1 2 3
7.
Swelling in feet/ankles upon waking in A.M. 0 1 2 3
8.
Puffiness beneath eyes in the morning 0 1 2 3
Unit
XI: RESPIRATORY SYSTEM
Part
A: RESPIRATORY SYSTEM
1.
Shortness of breath / labored breathing 0 1 2 3
2.
Chest tightness / pain 0 1 2 3
3.
Recurring / chronic cough 0 1 2 3
4.
Coughing up phlegm or blood 0 1 2 3
5.
Chest colds 0 1 2 3
Unit XI, Part A
(Cont.)
6.
Sensitive to smog / perfumes, etc 0 1 2 3
7.
Live / work with people who smoke 0 1 2 3
8.
Smoker -- currently or in past 3 years? N Y
9.
Chronic lung infections? N Y
10.
Exposure to chemicals, pesticides or radiation? N Y
Unit
XII: IMMUNE SYSTEM
Part
A: LOW-FUNCTION (HYPO IMMUNITY)
1.
Bleeding or sensitive gums 0 1 2 3
2.
Runny / sniffy nose 0 1 2 3
3.
Nose bleeds for no apparent cause 0 1 2 3
4.
Loss of sense of smell or taste 0 1 2 3
5.
Chest and throat infections 0 1 2 3
6.
Fever blisters, cold sores 0 1 2 3
7.
Wounds heal slowly 0 1 2 3
8.
Hair thinning / falling out / slow growing
0 1 2 3
9.
Ear infection / congestion 0 1 2 3
10.
Slow recovery from cold or flu 0 1 2 3
11.
Catch colds / flu easily, despite precautions 0 1 2 3
12.
Skin on back of arms is rough / bumpy 0 1 2 3
13.
Lymph glands swell? N Y
Part
B: EXCESSIVE FUNCTION (HYPER IMMUNITY)
1.
Known food sensitivity / allergy 0 1 2 3
2.
Some foods cause illness, anxiety or depression 0 1 2 3
3.
Stomach pain / G.I. tract discomfort 0 1 2 3
4.
Swallowing tablets is difficult 0 1 2 3
5.
Mucus in throat / chest 0 1 2 3
6.
Low grade fever from time to time 0 1 2 3
7.
Swollen / inflamed joints, body aches 0 1 2 3
8.
Swollen or sore tongue 0 1 2 3
9.
Ear stuffy / congested 0 1 2 3
10.
Sinus infection 0 1 2 3
11.
Runny nose / post nasal drip 0 1 2 3
12.
Alternating diarrhea and constipation 0 1 2 3
13.
Bed wetting? N
Y
14.
Attention deficit / hyperactivity? N Y
15.
Use aspirin, tylenol,
ibuprofen? N Y
16.
Use Cortisone, prednisone, steroids? N Y
17.
Mouth breather? N Y
18.
Skin disorder / rashes? N Y
19.
Bronchitis / asthma / chronic lung problems? N Y
20.
Recurring migraine headaches? N Y
21.
Eye itch / puffiness / discharge? N Y
Unit
XIII: BONES
Part
A: BONE INTEGRITY
1.
Cavities / dental weaknesses 0 1 2 3
2.
Bones sore / painful 0 1 2 3
3.
Pain in joints / extremities 0 1 2 3
4.
Eat meat with most meals? N Y
5. 3+ cups/day of carbonated beverages? N Y
6.
Gingivitis / gum sensitivity? N Y
7.
Use antacids at least once a day? N Y
8.
Presently wear dentures? N Y
9.
Any known bone deformities? N Y
10.
Diagnosed with arthritis / rheumatism? N Y
12.
Recent bone fracture (past 2 years)? N Y
For women:
13.
Post menopausal? N Y
Unit
XIV: SOFT TISSUE
Part
A: MUSCLE
1.
Muscle cramps 0 1 2 3
2.
Muscle spasms 0 1 2 3
3.
Tension in shoulder muscles 0 1 2 3
4.
Pain in neck (fibronalgia) 0 1 2 3
5.
Unable to sit for long periods 0 1 2 3
6.
Stiff upon awakening 0 1 2 3
7.
Pain / cramps in arms, legs, hands and feet 0 1 2 3
8.
Fibromyalgia? N Y
Part
B: CONNECTIVE TISSUE
1.
Injured tendons / ligaments 0 1 2 3
2.
Double jointed 0 1 2 3
3.
Aching joints 0 1 2 3
4.
Back pain 0 1 2 3
5.
Tendonitis 0 1 2 3
6.
Knees / elbows swollen 0 1 2 3
7.
Bursitis 0 1 2 3
8.
Slipped / herniated disc? N Y
9.
Height loss? N Y
10.
Bruise / injure easily? N Y
Unit
XV: NERVOUS SYSTEM
Part
A: NERVOUS SYSTEM
1.
Tingling sensation under the skin 0 1 2 3
2.
Noises / ringing in ears 0 1 2 3
3.
Loss of balance / vertigo 0 1 2 3
4.
Abnormally exhausted 0 1 2 3
5.
Light headedness / dizziness 0 1 2 3
6.
Nervousness / restlessness 0 1 2 3
7.
Grip strength weaker than usual 0 1 2 3
8.
Arms and legs feel heavy 0 1 2 3
9.
Numbness in hands and feet 0 1 2 3
10.
Heavy headed feeling 0 1 2 3
11.
Tremor in hands 0 1 2 3
12.
Clumsiness / bad coordination 0 1 2 3
13.
Convulsions / seizures? N Y
14.
Have shingles / herpes? N Y
15.
Accident prone? N Y
16.
Need for 10 or more hours of sleep? N Y
17.
Noticeable loss of muscle mass? N Y
Unit
XVI: SLEEP
Part
A: SLEEP PATTERNS
1.
Nightmares / intense dreams 0 1 2 3
2.
Insomnia 0 1 2 3
3.
"Toss and turn" sleeper 0 1 2 3
4.
Restless legs when laying down 0 1 2 3
5.
Currently using a sleep aid? N Y
6.
Wake up frequently during the night? N Y
7.
Wake early, can't fall back to sleep? N
Y
8.
Sleep walk / talks in sleep? N Y