Systems Survey Form Page 2
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21 2 3
GROUP 7A
1 2 3
107
Insomnia
170
Weakness after colds, influenza
108
Nervousness
171
Exhaustion - muscular and nervous
109
172
Can't gain weight
Respiratory disorders
110
Intolerance to heat
GROUP 8
111
Highly emotional
173
Muscle weakness
112
Flush easily
174
Lack of Stamina
113
Night sweats
175
Drowsiness after eating
114
Thin, moist skin
176
Muscular soreness
115
Inward trembling
177
Rapid heart beat
116
Heart palpitates
178
Hyper-irritable
117
Increased appetite without weight gain
179
Feeling of a band around your head
118
Pulse fast at rest
180
Melancholia (feeling of sadness)
119
Eyelids and face twitch
181
Swelling of ankles
120
Irritable and restless
182
Diminished urination
121
Can't work under pressure
183
Tendency to consume sweets or carbohydrates
GROUP 7B
184
Muscle spasms
122
185
Increase in weight
Blurred vision
123
Decrease in appetite
186
Loss of muscular control
124
187
Fatigue easily
Numbness
125
188
Ringing in ears
Night sweats
126
Sleepy during day
189
Rapid digestion
127
190
Sensitive to cold
Sensitivity to noise
128
191
Dry or scaly skin
Redness of palms of hands and bottom of feet
129
Constipation
192
Visible veins on chest and abdomen
130
193
Mental sluggishness
Hemorrhoids
131
194
Hair coarse, falls out
Apprehension (feeling that something bad will happen)
132
Headaches upon arising, wear off during day
195
Nervousness causing loss of appetite
133
196
Slow pulse, below 65
Nervousness with indigestion
134
197
Frequency of urination
Gastritis
135
Impaired hearing
198
Forgetfulness
136
199
Reduced initiative
Thinning hair
GROUP 7C
FEMALE ONLY
137
200
Failing memory
Very easily fatigued
138
Low blood pressure
201
Premenstrual tension
139
Increased sex drive
202
Painful menses
140
203
Headaches, "splitting or rending" type
Depressed feelings before menstruation
141
Decreased sugar tolerance
204
Menstruation excessive and prolonged
205
Painful breasts
GROUP 7D
206
Menstruate too frequently
142
Abnormal thirst
207
Vaginal discharge
143
Bloating of abdomen
208
Hysterectomy / ovaries removed
144
Weight gain around hips or waist
209
Menopausal hot flashes
145
Sex drive reduced or lacking
210
Menses scanty or missed
146
Tendency to ulcers, colitis
211
Acne, worse at menses
147
Increased sugar tolerance
212
Depression of long standing
148
Women: menstrual disorders
149
MALE ONLY
Young girls: lack of menstrual function
213
Prostate trouble
GROUP 7E
214
Urination difficult or dribbling
150
Dizziness
215
Night urination frequent
151
Headaches
216
Depression
152
Hot flashes
217
Pain on inside of legs or heels
153
Increased blood pressure
218
Feeling of incomplete bowel evacuation
154
Hair growth on face or body (female)
219
Lack of energy
155
Sugar in urine (not diabetes)
220
Migrating aches and pains
156
Masculine tendencies (female)
221
Tire too easily
GROUP 7F
222
Avoids activity
157
Weakness, dizziness
223
Leg nervousness at night
158
Chronic fatigue
224
Diminished sex drive
159
Low blood pressure
160
Nails weak, ridged
List the five main complaints you have in the order of their importance:
161
Tendency to hives
1.
162
Arthritic tendencies
163
Perspiration increase
2.
164
Bowel disorders
165
Poor circulation
3.
166
Swollen ankles
167
Crave salt
4.
168
Brown spots or bronzing of skin
169
Allergies - tendency to asthma
5.
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