INSTRUCTIONS
Check the box that applies to you. Check either:
MILD (problem occurs rarely)
MODERATE (problem occurs several times per month)
SEVERE (problem is constant or almost constant)
If you do not experience a symptom, leave it blank by not checking any boxes.
Sympathetic Dominance
Relates to a "stuck gas pedal" in the nervous system. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
1.
1
2
3
Acid foods upset
2.
1
2
3
Get chilled often
3.
1
2
3
"Lump" in throat
4.
1
2
3
Dry mouth, eyes and nose
5.
1
2
3
Pulse speeds after meal
6.
1
2
3
Keyed up - fail to calm
7.
1
2
3
Cuts heal slowly
8.
1
2
3
Gag Easily
9.
1
2
3
Unable to relax; startles easily
10.
1
2
3
Extremities cold and clammy
11.
1
2
3
Strong light irritates
12.
1
2
3
Urine amount reduced
13.
1
2
3
Heart pounds after retiring
14.
1
2
3
"Nervous" stomach
15.
1
2
3
Appetite reduced
16.
1
2
3
Cold sweats often
17.
1
2
3
Fever easily raised
18.
1
2
3
Neuralgia - like pains
19.
1
2
3
Staring, blinks little
20.
1
2
3
Sour stomach often
Parasympathetic Dominance
Relates to a "stuck break pedal" in the nervous system. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
21.
1
2
3
Joint stiffness on arising
22.
1
2
3
Muscle, leg, or toe cramps at night
23.
1
2
3
"Butterfly" stomach cramps
24.
1
2
3
Eyes or nose watery
25.
1
2
3
Eyes blink often
26.
1
2
3
Eyelids swollen and puffy
27.
1
2
3
Indigestion soon after meals
28.
1
2
3
Always seems hungry; feels light headed often
29.
1
2
3
Digestion rapid
30.
1
2
3
Vomiting frequent
31.
1
2
3
Hoarseness frequent
32.
1
2
3
Breathing irregular
33.
1
2
3
Pulse slow; feels "irregular"
34.
1
2
3
Gagging reflex slow
35.
1
2
3
Difficulty swallowing
36.
1
2
3
Constipation, diarrhea alternating
37.
1
2
3
"Slow starter"
38.
1
2
3
Get "chilled" frequently
39.
1
2
3
Perspire easily
40.
1
2
3
Circulation poor, sensitive to cold
41.
1
2
3
Frequent colds, asthma, bronchitis
Sugar Handling
Processing and managing carbohydrates eaten in the diet. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
42.
1
2
3
Eat when nervous
43.
1
2
3
Excessive appetite
44.
1
2
3
Hungry between meals
45.
1
2
3
Irritable before meals
46.
1
2
3
Get "shaky" if hungry
47.
1
2
3
Fatigue, eating relieves
48.
1
2
3
"Lightheaded" if meals delayed
49.
1
2
3
Heart palpitates if meals missed
50.
1
2
3
Afternoon headaches
51.
1
2
3
Overeating sweets upsets
52.
1
2
3
Awaken after few hours sleep, hard to get back to sleep
53.
1
2
3
Afternoon craving of candy, coffee
54.
1
2
3
Moods of depression - "blues"
55.
1
2
3
Cravings for sweets or snacks
Cardiovascular
Function of heart and circulatory systems. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
56.
1
2
3
Hands and feet go to sleep easily
57.
1
2
3
Sigh frequently, "air" hunger
58.
1
2
3
Aware of "breathing heavily"
59.
1
2
3
High altitude discomfort
60.
1
2
3
Opens windows in closed rooms
61.
1
2
3
Susceptible to colds and fevers
62.
1
2
3
Afternoon "yawner"
63.
1
2
3
Get "drowsy" often
64.
1
2
3
Swollen ankles, worse at night
65.
1
2
3
Muscle cramps, worse during exercise; get "charley horses"
66.
1
2
3
Shortness of breath on exertion
67.
1
2
3
Dull pain in chest or radiating into left arm, worse on exertion
68.
1
2
3
Bruise easily, "black and blue" spots
69.
1
2
3
Tendency to anemia
70.
1
2
3
"Nose bleeds" frequent
71.
1
2
3
Noises in head, or "ringing in ears"
72.
1
2
3
Tension under the breastbone, or feeling of "tightness", worse on exertion
Liver & Gallbladder
Detoxification and fat metabolism. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
73.
1
2
3
Dizziness
74.
1
2
3
Dry skin
75.
1
2
3
Burning feet
76.
1
2
3
Blurred vision
77.
1
2
3
Itching skin and feet
78.
1
2
3
Excessive falling hair
79.
1
2
3
Frequent skin rashes
80.
1
2
3
Bitter, metallic taste in mouth in mornings
81.
1
2
3
Bowel movements painful or hard
82.
1
2
3
Worrier, feels insecure
83.
1
2
3
Feeling queasy, headache over eyes
84.
1
2
3
Greasy foods upset
85.
1
2
3
Stool light colored
86.
1
2
3
Skin peels on foot soles
87.
1
2
3
Pain between shoulder blades
88.
1
2
3
Use laxatives
89.
1
2
3
Stools alternate from soft to watery
90.
1
2
3
History of gallbladder attacks or gallstones
91.
1
2
3
Sneezing attacks
92.
1
2
3
Nightmare type bad dreams
93.
1
2
3
Bad breath (halitosis)
94.
1
2
3
Milk products cause distress
95.
1
2
3
Sensitve to hot weather
96.
1
2
3
Burning or itching anus
97.
1
2
3
Crave sweets
Digestion
Ability to metabolize proteins. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
98.
1
2
3
Loss of taste for meat
99.
1
2
3
Lower bowel gas several hours after eating
100.
1
2
3
Burning stomach sensations, eating relieves
101.
1
2
3
Coated tongue
102.
1
2
3
Pass large amounts of foul-smelling gas
103.
1
2
3
Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hours
104.
1
2
3
Mucous colitis or "irritable bowel"
105.
1
2
3
Gas shortly after eating
106.
1
2
3
Stomach "bloating" after eating
Endocrine (Hormone) System
Hormones are a major communication system, crucial for maintaining all major body systems.
Thyroid: Controls speed of metoabolism, passage of nutrients into cells and waste out of cells.
Pituitary: Controls digestion and reproduction systems.
Adrenals: Controls energy, emergency response, fluid balance.
Hyperthyroid - "Overspeeding" Thyroid. Read More.
1 = Mild, 2 = Moderate, 3 = Severe
107.
1
2
3
Insomnia
108.
1
2
3
Nervousness
109.
1
2
3
Can't gain weight
110.
1
2
3
Intolerance to heat
111.
1
2
3
Highly emotional
112.
1
2
3
Flush easily
113.
1
2
3
Nights sweats
114.
1
2
3
Thin, moist skin
115.
1
2
3
Inward trembling
116.
1
2
3
Heart palpitates
117.
1
2
3
Increased appetite without weight gain
118.
1
2
3
Pulse fast at rest
119.
1
2
3
Eyelids and face twitch
120.
1
2
3
Irritable and restless
121.
1
2
3
Can't work under pressure
Hypothyroid "Sluggish" Thyroid
Read more.
1 = Mild, 2 = Moderate, 3 = Severe
122.
1
2
3
Increase in weight
123.
1
2
3
Decrease in appetite
124.
1
2
3
Fatigue easily
125.
1
2
3
Ringing in ears
126.
1
2
3
Sleepy during day
127.
1
2
3
Sensitive to cold
128.
1
2
3
Dry or scaly skin
129.
1
2
3
Constipation
130.
1
2
3
Mental sluggishness
131.
1
2
3
Hair coarse, falls out
132.
1
2
3
Headaches upon arising, wear off during day
133.
1
2
3
Slow pulse, below 65
134.
1
2
3
Frequency of urination
135.
1
2
3
Impaired hearing
136.
1
2
3
Reduced initiative
Hyperpituitary "Overspeeding" Pituitary
Read more.
1 = Mild, 2 = Moderate, 3 = Severe
137.
1
2
3
Failing memory
138.
1
2
3
Low blood pressure
139.
1
2
3
Increased sex drive
140.
1
2
3
Headaches, "splitting or rending"
141.
1
2
3
Decreased sugar tolerance
Hyporpituitary "Sluggish" Pituitary
Read more.
1 = Mild, 2 = Moderate, 3 = Severe
142.
1
2
3
Abnormal thirst
143.
1
2
3
Bloating of abdomen
144.
1
2
3
Weight gain around hips or waste
145.
1
2
3
Sex drive reduced or lacking
146.
1
2
3
Tendency to ulcers, colitis
147.
1
2
3
Increased sugar tolerance
148.
1
2
3
Women: menstrual disorders
149.
1
2
3
Young girls: lack of menstrual function
Hyperadrenal "Overspeeding" Adrenals
Read more.
1 = Mild, 2 = Moderate, 3 = Severe
150.
1
2
3
Dizziness
151.
1
2
3
Headaches
152.
1
2
3
Hot flashes
153.
1
2
3
Increased blood pressure
154.
1
2
3
Hair growth on face or body (female)
155.
1
2
3
Sugar in urine (not diabetes)
156.
1
2
3
Masculine tendencies (female)
Hypoadrenal "Sluggish" Adrenals
Read more.
1 = Mild, 2 = Moderate, 3 = Severe