NUTRITION:   PATIENT SYSTEM SURVEY FORM
Please make sure you fill in every question, the form will not let you submit unless every question is answered. If there is a question where you do not have symptoms make sure to press NO SYMPTOMS.
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Group 1 Please make sure you fill in every question, the form will not let you submit unless every question is answered. If there is a question where you do not have symptoms make sure to press NO SYMPTOMS. *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Acid Foods Upset
Feel chilled often
Lump in throat
Dry mouth, eyes, nose
Pulse speeds after meals
Keyed up, unable to calm
Cuts heal slowly
Gag easily
Unable to relax; startle easily
Extremities cold and/or clammy
Strong light irritates
Urine amount reduced
Heart pounds after retiring
Nervous Stomach
Appetite Reduced
Cold sweats often
Body temperature rises easily
Skin Sensitive to touch
Staring, Blink little
Frequently have a sour stomach
Group 2 *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Joint Stiffness after arising
Muscle leg toe cramps at night
Butterfly stomach, cramps
Eyes or nose watery
Eyes blink often
Eyelids swollen or puffy
Indigestion soon after meals
Always seem hungry; feel lightheaded often
Food digests rapidly
Vomit frequent
Frequently hoarse
Irregular breathing
Pulse slow or feels "irregular"
Slow gag reflex
Difficulty swallowing
Alternating constipation and diarrhea
Slow starter
Not easily chilled
Perspire easily
Poor circulation/ sensitive to cold
Subject to colds, asthma and bronchitis
Group 3 *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Eat when nervous
Excessive appetite
Hungry between meals
Irritable before meals
Get Shaky if hungry
Feeling fatigued, eating relieves
Lightheaded if meals missed or delayed
Heart Palpitates if meals missed or delayed
Afternoon headaches
Upset feeling from excessive eating of sweets
Awaken after few hours sleep- hard to get back to sleep
Crave candy or coffee in afternoons
moods of depression- blues or melancholy
abnormal craving for sweets or snacks
Group 4
mild symptoms
moderate symptoms
severe symptoms
no symptoms
Hands and feet go to sleep easily, numbness
Sign frequently, "air hunger"
Aware of "breathing heavily"
Discomfort at high altitude
Open windows in closed room
Susceptible to colds and fevers
Afternoon "yawner"
Get "drowsy" often
Swollen ankles worse at night
Muscle cramps, worse during exercise get charley horses
shortness of breath on exertion
dull pain in chest or radiating into left arm, worse on exertion
Bruise easily, "black/blue" spots on arms or legs
Tendency to anemia
Frequently have nose bleeds
ringing in ears or noises in head
tension under the breastbone or feeling of tightness, in the chest
dizziness
Clear selection
Group 5 *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No symptoms
Dry Skin
Burning feet
Blurred vision
Itching skin and feet
Excessive falling hair
frequent skin rashes
Bitter or metallic taste in mouth in mornings
Bowel movements painful or difficult
feelings of worry, dread, or insecurity
feeling queasy, headache over eyes
greasy foods upset
stools light colored
skin peels on foot soles
pain between shoulder blades
using laxatives
stools alternate from soft to watery
history of gallbladder attacks or gallstones
sneezing attacks
dreaming, nightmare type bad dreams
bad breath (halitosis)
milk products cause distress
sensitive to hot weather
burning to itching anus
crave sweets
Group 6 *
Mild Symptoms
Moderate Symptoms
Severe symptoms
No Symptoms
Loss of taste for meat
Lower bowel gas several hours after eating
burning stomach sensations eating relieves
coated tounge
pass alrge amounts of foul- smelling gas
indigestion 1/2-1 hour after eating; may be up to 3-4 hours
Mucus colitis or "irritable bowel"
Gas shortly after eating
stomach "bloating after eating
Group 7 A *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No symptoms
Insomnia
Nervousness
Cant gain weight
Intolerance to heat
Highly emotional
flush easily
night sweats
skin is thin and moist
inward tremling
heart palpitates
increased appetite without weight gain
pulse races when resting
eyelids and face twitch
irritable and restless
cant work under pressure
Group 7B *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Noticeable weight gain
decrease in appetite
easily fatigued
ringing in ears
sleepy during day
sensitive to cold
dry or scaly skin
constipation
mental sluggishness
hair coarse, falls out
headaches upon arising, wear off during day
slow pulse, below 65
frequent urination
impaired hearing
reduced initiative
Group 7C *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Failing Memory
Low blood pressure
Increased sex drive
Headaches, "splitting or rending" type
Decreased sugar tolerance
Group 7D *
Mild Symptoms
Moderate symptoms
Severe Symptoms
No symptoms
Abnormal thirst
Bloating of the abdomen
weight gain around the hips or waist
sex drive reduced or lacking
tendency towards ulcers and colitis
increased sugar tolerance
women: menstrual disorders
young girls: lack of menstrual function
Group 7 E *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No symptoms
Dizziness
headaches
hot flashes
increased blood pressure
(female) hair growth on face or body
sugar in urine (not diabetes)
(female) masculine tendencies
Group 7F *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Weakness and or dizziness
chronic fatigue
low blood pressure
nails weak and or rigid
tendency toward hives
arthritic tendencies
perspiration increase
bowel disorders
poor circulation
swollen ankles
crave salt
brown spots or bronzing of skin
allergies- tendency to asthma
weakness after colds or influenze
muscular and nervous exhaustion
respiratory disorders
Group 8 *
Mild Symptoms
Moderate Symptoms
Severe Symptoms
No Symptoms
Apprehension
Irritability
Morbid fears
never seem to get well
forgetfulness
Indigestion
poor apprtite
craving for sweets
muscular soreness
depression, feelings of dread
noise sensitivity
acoustic hallucinations
tendency to cry without reason
hair is course and or thinning
weakness
Fatigue
skin sensitive to touch
tendency toward hives
nervousness
headache
insomnia
anxiety
anorexia
inability to concentrate; confusion
frequent stuffy nose; sinus infections
allergy to some foods
loose joints
Female Only
mild symptoms
moderate symptoms
severe symptoms
no symptoms
Very Easily Fatigued
Premenstrual Tension
Painful Memses
Depressed Feelings before menstruation
Painful Breasts
Menstruate too frquently
vaginal discharge
hysterectomy/ovaries removed
menopausal hot flashes
menses scanty or missed
acne, worse at menses
long standing depression
Clear selection
Male Only
Mild Symptoms
Moderate Symptoms
Severe symptoms
No symptoms
Prostate Trouble
Urination difficult or dribbling
frequent nighttime urination
depression
pain on nside of legs or heels
feeling of incomplete bowl evacuation
lack of energy
migrating aches and pains
too easily tired
avoid activity
leg nervousness at night
diminished sex drive
Clear selection
Top 5 main health complaints Please make sure you fill in every question, the form will not let you submit unless every question is answered. If there is a question where you do not have symptoms make sure to press NO SYMPTOMS.  Thank you, Dr. Bente and Staff! *
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