Systems Survey Form
ADVERTISEMENT
1
2SYSTEMS SURVEY FORM
Patient
Doctor
Date
¨
¨
/
/
Birth Date
Approx Weight
Sex: Male
Female
¨
¨
Pulse: Recumbent
Standing
Vegetarian
Gluten-free
¨
Blood pressure: Recumbent
Standing
Ragland's Test is Positive
/
/
INSTRUCTIONS: Fill in only the circles which apply to you.
1 2 3
MILD symptoms (occurs rarely).
52
Awaken after few hours sleep - hard to get back to sleep
MODERATE symptoms (occurs several times a month).
53
Crave candy or coffee in afternoons
SEVERE symptoms (occurs almost constantly)
54
Moods of depression - "blues" or melancholy
Leave circles BLANK if they don't apply to you!
55
Abnormal craving for sweets or snacks
GROUP 4
1 2 3
GROUP 1
56
Hands and feet go to sleep easily, numbness
1
Acid foods upset
57
Sigh frequently, "air hunger"
2
Get chilled often
58
Aware of "breathing heavily"
3
"Lump" in throat
59
High altitude discomfort
4
Dry mouth-eyes-nose
60
Opens windows in closed rooms
5
Pulse speeds after meal
61
Susceptible to colds and fevers
6
Keyed up - fail to calm
62
Afternoon "yawner"
7
Cut heals slowly
63
Get "drowsy" often
8
Gag easily
64
Swollen ankles, worse at night
9
Unable to relax; startles easily
65
Muscle cramps, worse during exercise; get "charley horses"
10
Extremities cold, clammy
66
Shortness of breath on exertion
11
Strong light irritates
67
Dull pain in chest or radiating into left arm, worse on exertion
12
Urine amount reduced
68
Bruise easily, "black and blue" spots
13
Heart pounds after retiring
69
Tendency to anemia
14
"Nervous" stomach
70
"Nose bleeds" frequent
15
Appetite reduced
71
Noises in head, or "ringing in ears"
16
Cold sweats often
72
Tension under the breastbone, or feeling of "tightness",
17
Fever easily raised
worse on exertion
18
Neuralgia-like pains
GROUP 5
19
Staring, blinks little
73
Dizziness
20
Sour stomach often
74
Dry skin
GROUP 2
75
Burning feet
21
Joint stiffness on arising
76
Blurred vision
22
Muscle-leg-toe cramps at night
77
Itching skin and feet
23
"Butterfly" stomach, cramps
78
Excessive falling hair
24
Eyes or nose watery
79
Frequent skin rashes
25
Eyes blink often
80
Bitter, metallic taste in mouth in mornings
26
Eyelids swollen, puffy
81
Bowel movements painful or difficult
27
Indigestion soon after meals
82
Worrier, feels insecure
28
Always seems hungry; feels "lightheaded" often
83
Feeling queasy; headache over eyes
29
Digestion rapid
84
Greasy foods upset
30
Vomiting frequent
85
Stools light colored
31
Hoarseness frequent
86
Skin peels on foot soles
32
Breathing irregular
87
Pain between shoulder blades
33
Pulse slow; feels "irregular"
88
Use laxatives
34
Gagging reflex slow
89
Stools alternate from soft to watery
35
Difficulty swallowing
90
History of gallbladder attacks or gallstones
36
Constipation, diarrhea alternating
91
Sneezing attacks
37
"Slow starter"
92
Dreaming, nightmare type bad dreams
38
Get "chilled" infrequently
93
Bad breath (halitosis)
39
Perspire easily
94
Milk products cause distress
40
Circulation poor, sensitive to cold
95
Sensitive to hot weather
41
Subject to colds, asthma, bronchitis
96
Burning or itching anus
GROUP 3
97
Crave sweets
42
Eat when nervous
GROUP 6
43
Excessive appetite
98
Loss of taste for meat
44
Hungry between meals
99
Lower bowel gas several hours after eating
45
Irritable before meals
100
Burning stomach sensations, eating relieves
46
Get "shaky" if hungry
101
Coated tongue
47
Fatigue, eating relieves
102
Pass large amounts of foul-smelling gas
48
"Lightheaded" if meals delayed
103
Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs.
49
Heart palpitates if meals missed or delayed
104
Mucous colitis or "irritable bowel"
50
Afternoon headaches
105
Gas shortly after eating
51
Overeating sweets upsets
106
Stomach "bloating" after eating
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal