Symptom and System Analysis

  • Part 1:
  • Part 2
  • Part 3
  • Part 4
  • Part 5

Personal Data

This questionnaire consists of 321 questions and is divided into 5 parts. Please allow at least 30 minutes to complete and note it can't be saved until you have completed the whole form. PLEASE MAKE SURE YOU TAKE YOUR TIME AND FILL IN EVERY QUESTION. SKIPPING QUESTIONS WILL RESULT IN ERROR MESSAGES.

Full Name

Email

DOB (yy/mm/dd)

Gender

Phone Number

Please list your five major health concerns in order of importance:

PART I: Read the following questions and circle the number that applies:

DIET: 1. Alcohol

DIET: 2. Artificial sweeteners

DIET: 3. Candy, desserts, refined sugar

DIET: 4. Carbonated beverages

DIET: 5. Chewing tobacco

DIET: 6. Cigarettes

DIET: 7. Cigars/pipes

DIET: 8. Caffeinated beverages

DIET: 9. Fast foods

DIET: 10. Fried foods

DIET: 11. Luncheon meats

DIET: 12. Margarine

DIET: 13. Milk products

DIET: 14. Radiation exposure ( via food or work )

DIET: 15. Refined flour/baked goods

DIET: 16. Vitamins and minerals

DIET: 17. Water, distilled

DIET: 18. Tap water consumption

DIET: 19. Mineral water consumption

DIET: 20. Diet often for weight control

LIFESTYLE: 21. Exercise per week

LIFESTYLE: 22. Changed jobs

LIFESTYLE: 23. Divorced

LIFESTYLE: 24. Work over 60 hours/week

Indicate any medications you're currently taking or have taken in the last month.

MEDICATIONS: 25. Antacids

MEDICATIONS: 26. Antianxiety medications

MEDICATIONS: 27. Antibiotics

MEDICATIONS: 28. Anticonvulsants

MEDICATIONS: 29. Antidepressants

MEDICATIONS: 30. Antifungals

MEDICATIONS: 31. Aspirin/Ibuprofen

MEDICATIONS: 32. Asthma inhalers

MEDICATIONS: 33. Beta blockers

MEDICATIONS: 34. Birth control pills/implant contraceptives

MEDICATIONS: 35. Chemotherapy

MEDICATIONS: 36. Cholesterol lowering medications

MEDICATIONS: 37. Cortisone/steroids

MEDICATIONS: 38. Diabetic medications/insulin

MEDICATIONS: 39. Diuretics

MEDICATIONS: 40. Estrogen or progesterone (pharmaceutical, prescription)

MEDICATIONS: 41. Estrogen or progesterone (natural)

MEDICATIONS: 42. Heart medications

MEDICATIONS: 43. High blood pressure medications

MEDICATIONS: 44. Laxatives

MEDICATIONS: 45. Recreational drugs

MEDICATIONS: 46. Relaxants/Sleeping pills

MEDICATIONS: 47. Testosterone (natural or prescription)

MEDICATIONS: 48. Thyroid medication

MEDICATIONS: 49. Acetaminophen (Tylenol)

MEDICATIONS: 50. Ulcer medications

MEDICATIONS: 51. Sildenafal citrate (Viagra)

Section 1

Section 1: 52. Belching or gas within one hour after eating

Section 1: 53. Heartburn or acid reflux

Section 1: 54. Bloating within one hour after eating

Section 1: 55. Vegan diet (no dairy, meat, fish or eggs)

Section 1: 56. Bad breath (halitosis)

Section 1: 57. Loss of taste for meat

Section 1: 58. Sweat has a strong odor

Section 1: 59. Stomach upset by taking vitamins

Section 1: 60. Sense of excess fullness after meals

Section 1: 61. Feel like skipping breakfast

Section 1: 62. Feel better if you don’t eat

Section 1: 63. Sleepy after meals

Section 1: 64. Fingernails chip, peel or break easily

Section 1: 65. Anemia unresponsive to iron

Section 1: 66. Stomach pains or cramps

Section 1: 67. Diarrhea, chronic

Section 1: 68. Diarrhea shortly after meals

Section 1: 69. Black or tarry colored stools

Section 1: 70. Undigested food in stool

Section 2

Section 2: 71. Pain between shoulder blades

Section 2: 72. Stomach upset by greasy foods

Section 2: 73. Greasy or shiny stools

Section 2: 74. Nausea

Section 2: 75. Sea, car, airplane or motion sickness

Section 2: 76. History of morning sickness

Section 2: 77. Light or clay colored stools

Section 2: 78. Dry skin, itchy feet or skin peels on feet

Section 2: 79. Headache over eyes

Section 2: 80. Gallbladder attacks

Section 2: 81. Gallbladder removed

Section 2: 82. Bitter taste in mouth, especially after meals

Section 2: 83. Become sick if you were to drink wine

Section 2: 84. Easily intoxicated if you were to drink wine

Section 2: 85. Easily hung over if you were to drink wine

Section 2: 86. Alcohol per week

Section 2: 87. Recovering alcoholic

Section 2: 88. History of drug or alcohol abuse

Section 2: 89. History of hepatitis

Section 2: 90. Long term use of prescription/recreational drugs

Section 2: 91. Sensitive to chemicals (perfume, cleaning agents, etc.)

Section 2: 92. Sensitive to tobacco smoke

Section 2: 93. Exposure to diesel fumes

Section 2: 94. Pain under right side of rib cage

Section 2: 95. Hemorrhoids or varicose veins

Section 2: 96. Nutrasweet (aspartame) consumption

Section 2: 97. Sensitive to Nutrasweet (aspartame)

Section 2: 98. Chronic fatigue or Fibromyalgia

Section 3

Section 3: 99. Food allergies

Section 3: 100. Abdominal bloating 1 to 2 hours after eating

Section 3: 101. Specific foods make you tired or bloated

Section 3: 102. Pulse speeds after eating

Section 3: 103. Airborne allergies

Section 3: 104. Experience hives

Section 3: 105. Sinus congestion,

Section 3

Section 3: 106. Crave bread or noodles

Section 3: 107. Alternating constipation and diarrhea

Section 3: 108. Crohn's disease

Section 3: 109. Wheat or grain sensitivity

Section 3: 110. Dairy sensitivity

Section 3: 111. Are there foods you could not give up

Section 3: 112. Asthma, sinus infections, stuffy nose

Section 3: 113. Bizarre vivid dreams, nightmares

Section 3: 114. Use over-the-counter pain medications

Section 3: 115. Feel spacey or unreal

Section 4

Section 4: 116. Anus itches

Section 4: 117. Coated tongue

Section 4: 118. Feel worse in moldy or musty place

Section 4: 119. Taken antibiotic for a total accumulated time of

Section 4: 120. Fungus or yeast infections

Section 4: 121. Ring worm

Section 4: 122. Yeast symptoms increase with sugar, starch or alcohol

Section 4: 123. Stools hard or difficult to pass

Section 4: 124. History of parasites

Section 4: 125. Less than one bowel movement per day

Section 4: 126. Stools have corners or edges, are flat or ribbon shaped

Section 4: 127. Stools are not well formed (loose)

Section 4: 128. Irritable bowel or mucus colitis

Section 4: 129. Blood in stool

Section 4: 130. Mucus in stool

Section 4: 131. Excessive foul smelling lower bowel gas

Section 4: 132. Bad breath or strong body odors

Section 4: 133. Painful to press along outer sides of thighs (Iliotibial Band)

Section 4: 134. Cramping in lower abdominal region

Section 4: 135. Dark circles under eyes

Section 5

Section 5: 136. History of carpal tunnel syndrome

Section 5: 137. History of lower right abdominal pains or ileocecal valve problems

Section 5: 138. History of stress fracture

Section 5: 139. Bone loss (reduced density on bone scan)

Section 5: 140. Are you shorter than you used to be?

Section 5: 141. Calf, foot or toe cramps at rest

Section 5: 142. Cold sores, fever blisters or herpes lesions

Section 5: 143. Frequent fevers

Section 5: 144. Frequent skin rashes and/or hives

Section 5: 145. Herniated disc

Section 5: 146. Excessively flexible joints,

Section 5: 147. Joints pop or click

Section 5: 148. Pain or swelling in joints

Section 5: 149. Bursitis or tendonitis

Section 5: 150. History of bone spurs

Section 5: 151. Morning stiffness

Section 5: 152. Nausea with vomiting

Section 5: 153. Crave chocolate

Section 5: 154. Feet have a strong odor

Section 5: 155. History of anemia

Section 5: 156. Whites of eyes (sclera) blue tinted

Section 5: 157. Hoarseness

Section 5: 158. Difficulty swallowing

Section 5: 159. Lump in throat

Section 5

Section 5: 160. Dry mouth, eyes and/or nose

Section 5: 161. Gag easily

Section 5: 162. White spots on fingernails

Section 5: 163. Cuts heal slowly and/or scar easily

Section 5:164. Decreased sense of taste or smell

Section 6: 165. Experience pain relief with aspirin

Section 6

Section 6: 166. Crave fatty or greasy foods

Section 6: 167. Low- or reduced-fat diet

Section 6: 168. Tension headaches at base of skull

Section 6: 169. Headaches when out in the hot sun

Section 6: 170. Sunburn easily or suffer sun poisoning

Section 6: 171. Muscles easily fatigued

Section 6: 172. Dry flaky skin or dandruff

Section 7

Section 7: 173. Awaken a few hours after falling asleep, hard to get back to sleep

Section 7: 174. Crave sweets

Section 7: 175. Binge or uncontrolled eating

Section 7: 176. Excessive appetite

Section 7: 177. Crave coffee or sugar in the afternoon

Section 7: 178. Sleepy in afternoon

Section 7: 179. Fatigue that is relieved by eating

Section 7: 180. Headache if meals are skipped or delayed

Section 7: 181. Irritable before meals

Section 7: 182. Shaky if meals delayed

Section 7: 183. Family members with diabetes

Section 7: 184. Frequent thirst

Section 7: 185. Frequent urination

Section 8

Section 8: 186. Muscles become easily fatigued

Section 8: 187. Feel exhausted or sore after moderate exercise

Section 8: 188. Vulnerable to insect bites

Section 8: 189. Loss of muscle tone, heaviness in arms/legs

Section 8: 190. Enlarged heart or congestive heart failure

Section 8: 191. Pulse below 65 per minute

Section 8: 192. Ringing in the ears (Tinnitus)

Section 8: 193. Numbness, tingling or itching in hands and feet

Section 8: 194. Depressed

Section 8: 195. Fear of impending doom

Section 8: 196. Worrier, apprehensive, anxious

Section 8: 197. Nervous or agitated

Section 8: 198. Feelings of insecurity

Section 8: 199. Heart races

Section 8: 200. Can hear heart beat on pillow at night

Section 8: 201. Whole body or limb jerk as falling asleep

Section 8: 202. Night sweats

Section 8: 203. Restless leg syndrome

Section 8: 204. Cracks at corner of mouth (Cheilosis)

Section 8: 205. Fragile skin, easily chaffed, as in shaving

Section 8: 206. Polyps or warts

Section 8: 207. MSG sensitivity

Section 8: 208. Wake up without remembering dreams

Section 8: 209. Small bumps on back of arms

Section 8: 210. Strong light at night irritates eyes

Section 8: 211. Nose bleeds and/or tend to bruise easily

Section 8: 212. Bleeding gums especially when brushing teeth

Section 9

Section 9: 213. Tend to be a "night person"

Section 9: 214. Difficulty falling asleep

Section 9: 215. Slow starter in the morning

Section 9: 216. Tend to be keyed up, trouble calming down

Section 9: 217. Blood pressure above 120/80

Section 9: 218. Headache after exercising

Section 9: 219. Feeling wired or jittery after drinking coffee

Section 9: 220. Clench or grind teeth

Section 9: 221. Calm on the outside, troubled on the inside

Section 9: 222. Chronic low back pain, worse with fatigue

Section 9: 223. Become dizzy when standing up suddenly

Section 9: 224. Difficulty maintaining manipulative correction

Section 9: 225. Pain after manipulative correction

Section 9: 226. Arthritic tendencies

Section 9: 227. Crave salty foods

Section 9: 228. Salt foods before tasting

Section 9: 229. Perspire easily

Section 9: 230. Chronic fatigue, or get drowsy often

Section 9: 231. Afternoon yawning

Section 9: 232. Afternoon headache

Section 9: 233. Asthma, wheezing or difficulty breathing

Section 9: 234. Pain on the medial or inner side of the knee

Section 9: 235. Tendency to sprain ankles or "shin splints"

Section 9: 236. Tendency to need sunglasses

Section 9: 237. Allergies and/or hives

Section 9: 238. Weakness, dizziness

Section 10

Section 10: 239. Height over 6' 6

Section 10: 240. Early sexual development (before age 10)

Section 10: 241. Increased libido

Section 10: 242. Splitting type headache

Section 10: 243. Memory failing

Section 10: 244. Tolerate sugar, feel fine when eating sugar *

Section 10: 245. Height under 4' 10

Section 10: 246. Decreased libido

Section 10: 247. Excessive thirst

Section 10: 248. Weight gain around hips or waist

Section 10: 249. Menstrual disorders

Section 10: 250. Delayed sexual development

Section 10: 251. Tendency to ulcers or colitis

Section 11

Section 11: 252. Sensitive/allergic to iodine

Section 11: 253. Difficulty gaining weight, even with large appetite

Section 11: 254. Nervous, emotional, can't work under pressure

Section 11: 255. Inward trembling

Section 11: 256. Flush easily

Section 11: 257. Fast pulse at rest

Section 11: 258. Intolerance to high temperatures

Section 11: 259. Difficulty losing weight

Section 11: 260. Mentally sluggish, reduced initiative

Section 11: 261. Easily fatigued, sleepy during the day

Section 11: 262. Sensitive to cold, poor circulation (cold hands and feet)

Section 11: 263. Constipation, chronic

Section 11: 264. Excessive hair loss and/or coarse hair

Section 11: 265. Morning headaches, wear off during the day

Section 11: 266. Loss of lateral 1/3 of eyebrow

Section 11: 267. Seasonal sadness

Section 12

Section 12 - Men Only: 268. Prostate problems

Section 12 - Men Only: 269. Difficulty with urination, dribbling

Section 12 - Men Only: 270. Difficult to start and stop urine stream

Section 12 - Men Only: 271. Pain or burning with urination

Section 12 - Men Only: 272. Waking to urinate at night

Section 12 - Men Only: 273. Interruption of stream during urination

Section 12 - Men Only: 274. Pain on inside of legs or heels

Section 12 - Men Only: 275. Feeling of incomplete bowel evacuation

Section 12 - Men Only: 276. Decreased sexual function

Section 12 - Men Only: 276. Decreased sexual function

Section 13

Section 13 - Women Only: 277. Depression during periods

Section 13 - Women Only: 278. Mood swings associated with periods (PMS)

Section 13 - Women Only: 279. Crave chocolate around periods

Section 13 - Women Only: 280. Breast tenderness associated with cycle

Section 13 - Women Only: 281. Excessive menstrual flow

Section 13 - Women Only: 282. Scanty blood flow during periods

Section 13 - Women Only: 283. Occasional skipped periods

Section 13 - Women Only: 284. Variations in menstrual cycles

Section 13 - Women Only: 285. Endometriosis

Section 13 - Women Only: 286. Uterine fibroids

Section 13 - Women Only: 287. Breast fibroids, benign masses

Section 13 - Women Only: 288. Painful intercourse (dysparenia)

Section 13 - Women Only: 289. Vaginal discharge

Section 13 - Women Only: 290. Vaginal dryness

Section 13 - Women Only: 291. Vaginal itchiness

Section 13 - Women Only: 292. Gain weight around hips, thighs and buttocks

Section 13 - Women Only: 293. Excess facial or body hair

Section 13 - Women Only: 294. Hot flushes

Section 13 - Women Only: 295. Night sweats (in menopausal females)

Section 13 - Women Only: 296. Thinning skin

Section 14

Section 14: 297. Aware of heavy and/or irregular breathing

Section 14: 298. Discomfort at high altitudes

Section 14: 299. " Air hunger" or sign frequently

Section 14: 300. Compelled to open windows in a closed room

Section 14: 301. Shortness of breath with moderate exertion

Section 14: 302. Ankles swell, especially at end of day

Section 14: 303. Cough at night

Section 14: 304. Blush or face turns red for no reason

Section 14: 305. Dull pain or tightness in chest and/or radiate into right arm, worse with exertion

Section 14: 306. Muscle cramps with exertion

Section 15

Section 15: 307. Pain in mid-back region

Section 15: 308. Puffy around the eyes, dark circles under eyes

Section 15: 309. History of kidney stones

Section 15: 310. Cloudy, bloody or darkened urine

Section 15: 311. Urine has a strong odor

Section 16

Section 16: 312. Runny or drippy nose

Section 16: 313. Catch colds at the beginning of winter

Section 16: 314. Mucus producing cough

Section 16: 315. Frequent colds or flu

Section 16: 316. Other infections (sinus, ear, lung, skin, bladder, kidney, etc.)

Section 16: 317. Never get sick

Section 16: 318. Acne (adult)

Section 16: 319. Itchy skin (Dermatitis)

Section 16: 320. Cysts, boils, rashes

Section 16: 321. History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition