,,,.' .."." ,

... SYMPTOM sURveY. FORM.. . . (Re$trlcted to Professional Use~

"" . -.

PATIENT.~.·~_-,-------;---:-:-~~~~.AGE D.OCTOR<-,-,-,--,-,-,---,-,,---,~~--,-_---,..:-,:c'-----,-'-OATEc-"'·"-·"·_· ~~-"-'. . : - .. :.' '.': .: .. - : - :".:' :.. .._.. ::-: .. : ::- .' : : - :'-'" .. ::::::::' '-::::-.'.".

··INSTRUC;TlbNS:N~~berthe. boxes whjcn.3pplytoy~u,. u~e (1) forMILD~ymptOms{oCCur <mts or fwiceambntl1}.(~)fOr.' MODERATE symptoms (Ocellr seVeral times it.month). a.nd(3) for SEVERE symptoms (youan~~wafu' oUt almost cc>psfuritly): .•...

... •~OUPONE.. 8 D Git'gEasiiy ..

.. ... ..

.9 0 .Unable 10 relax, startles eaSily

to 0 Extremities cold; clammy..0.$troriglightirritates

OUrinea~otlnt reduced.. .. , - ...

[J. Heart pOutlds afterretiring ..CJ .~Ner:V8us·stomach

'l>[]Acidf(jod~ upset

2 .'.D~et chiHed,ofteh ....... _.. . .....

3 <O~LtJnlp"irlthrOat ...•.•.....[JOo/f®Uthceyes-ndse •

.0••PJI~e~pa~.affer· Al~al

·O·~exeptip.~fctilt6ciilm••'.0.' dl.ltS heat stoWty' .:... ," ., , .

. "" .. ." ..

...... ...... ···········aROUPTWO. ':,:'.: -: -:::,: ',:: ,," :::, :.:.: -. ".', .. :. . . . ...

21D.J<jioistiftneSsafterarlslng .... >29EJ Oige$tion rapid

.22[JMJscle-I~-to~cr.nnp$~tl1ight $GO Vot'riffingfr¢quent -.

.: 23 O~utterlt:{'~to~ cl1i/l1ps 31 o Hoarneness frequ~nt .

24UE~sot~oseWateiY32IJ~reathin9trregliiar .. < .

". 25DE~$btirikoften" . . '33D~ulse$low;feeIS"irregDlar"26tJEYJIids~Ollef1>puffy . 34 O$aQging reflex sloW

27t:lln<:li~$ti()I1:;OOnaft~rineals' 35 [JDifficiittY~aIlowing28DAlwa~s~emhunglY; .:' . ··.360tohStipation,

. . ,

... feels 4ighfueaded" often ." ciiarrheaaltemating. . .

GROtJPt~REE

• 42[J Eatwh~.nnervous.43 D &ceSs~appetite

..... ::. :-J:':'" ...

• 44 ED Hungrybet'ween meals

'45. [j.'Imtktble p€fbre .m~ats

"46 [JGet"shaWihungrY.'47.·0··F<ltigue ••~ng. relieves

.48 0 QIJQhtheade(l~iffJ"lealSdelayed

4$ 0 Heait paipnates.jtmeats

. missed orde:/ayedo Afterrioql1headaches:.'. ::: .. ':: ': ".:-.:o .Overeating sWeets upsets.

520 .Awaken after fewhour$ sleep 55. , . .

- hard to get backto sleep

51

15 0 AWetitefedU~

1~ 0 COld sweats often

'17 0 Fever easily raised18 0 Neuralgia--like pains'

'19 O. Staring, blinks mUe

.'.20 o sour stomach frequent

370 "$loWstarter"38 '0 Get ''chilled'' lrifrequently39 U' Perspire easily .

... ....

40 [] Ciiculati()!'l POClr,..... . ....

. .•.•••sensitive tocc!ld41 OSubjt::cttoCoI~< ....

.asthrna;bronChitis

53 U Cra.vecandy orcoffee ..••

·inaftemooris .

Moods of depression-

"biues;'.crmelancholyAbnonnalcraviOf:j for

540

·0.. ... .. - -. ..

. sweets or snacks

'.' '. . .'.. .." ..

. .. ....." -.

56 0 Hancj~andfeetgotoSleep..eaSilY;.nUmbness

57 o sigh fr~uen1Iy,uair •.>htlOgei'"

580 Awarept"l;>reatnirig

. heavily" .••.... .••. ..'59 0 Highaftitucte discomfort

600 .Openswindowsin.........

ClOsed room .'.. .

[jSus~bletQ(xljds·.andf~J~rs· .:':

[]Aftsrrro{JO 'Yawner"

... " ..

. 630 Get"drowsy"often'

640 SW611enarikles

Wofseat night ..•[] M.uSclecrainp<wurse

. during exercis",;gl:!t"chartey horses"

. . .... .

.660 ShortneSs·o{breath

on exertion67 0 Dull pain in chest or

....radiatingiiito teft arm,

ll'iorseon exertion

680 Bruise 9a.sily,Ublack:andbtUe"'spots

690 Tendency to anemia ... .. -. .... .. -. .

70 0 .ar-l9Sebleeds" frequent .

71 o Noises. in head; Of. .

"ringihgiri' ears"72 0 Tension underthe

breastbone.. or feafingof "tightnesS",

•worse.onexertion

. -:..~: ". <:: :::::~':.'..:_.73 Df)izzmess74 [Jpryskin

.75 UBurningfeeL.. 7fj [JBiunedVisiOn

TlDltChmgskinand feet78 0 ExCeSsiVeii:l!linghair79 [Jfrequemskmrashe:;80 CJ Bitter, meta,"c taste

in motithinmomings.. a-t .•D•.BOWeI.movements"

·pafnfulordiff.cuH ..82· []Worrier, feels insecure

ss [JLoss of taste for meat99 LJLower bowel gas several

.hoursalterea.ting..1fJO.0 Bumingstornach· sensations,

. (,1aliii,g r¢lieves.. .

··107[]insorn~~ ••.•108[JNeivous~Ss .•......•.

·1098bai1'fgajriw~gh(••110.EJlnt~@I1cetoheat··111 []JligfllYemQtionar •112 []Fiusl1 easily .11.3·0 Ni{lntsWeatS·

.•114·0 Thin,moistskiri115 !"!lnWardtrembling .116 nHeartpa!piiates .117·0 Increased appetite without ..

. weighq:.iain11sDPutse fast at rest11.9.[Jeyelids and·face twitch120 Dlrritable and restless121 0Can't work under pressure

(8)122D.lncrease.in.weight·123 Doecreaseinappetlte··

. 124DFatiguee:asily .l?sD Flinging if) eaTS

...~§i~!i~i·····129 DConSupatlo!:i ...130 o Mentals!uggishnEiss .,:-T·· •..•........131LJHaircoa~e,fa{fs out: .•....·1320Head~$UPQnanslng·.

. wear off during day133 O· ·.SIOW uiSebelow65.. . ..... P ,. ..134 []. FrequenG)' ofurinatjon1$5Dlmpair~~arlng .1360 Reducedinitikmve.

.. . ..

.. .

..••.•SYMPTOMSORVEY FORM - Page 2

GROUPFJvE. .... .. 83 0 Feeling queasy; headache

o\iereyes . .. . ...•. 84 Clt3ieasy)oodS upset

< 85 D$toolsli~ht-Colored86· o Skin peels elf1 foot .sotes .

. 87 Dpain betWeen shoulder.. bladeS

88 0 Use laxatives. 89 1"1 StOOlSaltematetrorn

t., •._J

soft to watery ..90 rT HiStaryof gaflbladder ..

·artadffiorgall~ones·

GR()UPSIX .'Hl1 [JCoated tongue102 [] Passl<irgearnountsof

•foul-smelling gas103·· 0 IndigeStion 112 - 1 hour after

eating; may be up to 3:4 hours.. . .. _. .... .

•GR()UPSEVEN .....

(G)J]Faifingmemoiy.,-,-, LoWbloodprnssUret:1 fncreased sex:orive.[J.•·I-:f~aclach(.js,"$plrtting

or rendering" type•...141 [J Decreased sugar

tolerance

... (D) .14? n Abnormal thirst .

··n'--.--'143 ,--,Bloating of abdomen144 0 Weight gain around

hipsorwaist145U sexdj-ive reduced

<anacking ...146 0 Tendency to ulcers,

colitis14VOlncrea$ed sugar

to~rance···148CJ Women: menstrual

.diSorders .1490 Younggii1s: ..

lack otrnenstrua: .... fUnction .

91 r-l Sneezing attacksr=s92 LJ Dreaming;nightmarelypebad dreams ...

93 D.Bad breath (halitosis}.94 0 Milk products cause

distresso Sensitivato·hot weather·o Buming .oritching. anus[] Crave SWE:lets

959697

104 [J Mucous colitis or"imtabfeboWef'o Gas shortly. after eatil1go Stomach "bloating"

.after eating

.......;.:.,.. ..•..

105106

. (e)150 fl Dizziness1510 Headaches152 LJ .Hattlashes153 0 Increased blood

pressure154 0 HairgrovJth on face

.or body (female)155 o Sugar -inurine

(not diabetes) ....156 tJ ~ine tendencies

. (femaie)

. .•. (F) . .157 0 Weakness,· dizziness158· LJ Chronic fatigue·1590 Lowblocdpressure·160 r'~Nails, weak, ridged161 0 Tendency to hives162 ·r]·ArthTitic tendencies163 •[J PerspiratiOn increase164 0 8bweidiSotdEirs165[] Poor-circulationlW[JSwoUen ankles167 ["] Crave salt168 t:1·Brown spots or

bronzing of skin·169·· LJ AUef9ies~Jendency ..

tOasfhma170 0 Weakiiessaftereolcls,

influenza171 [] Exhaustion -muscular

and. nervous172 Respirafofydisarders

..,;"~' ,

... .... " ....

MALE ONLY213 0 Prostate trouble

... .'.

·214 LJUrination diffjcult

or dribbling

·215 CJ Night urination frequent

·:21,61....J Depression

217 :--1 Pain en inside of

legs or heels

2t8.DFeelirig ofincomplete

bowel evacuation2HlO laCk of energy

2200 MigraUngaches and pains

221{JTire too easily222[1 Avoids activity

.. 223 0 Leg· nerv()usnessat night

.2.240 Dirninished sex driVe

GROUPBGHT .FEMALE ONLY173. [JAppreheflSion .LJVery easily fatIgued174 Dtrritability ..":

r-· ... ··2dlflpremenstrual tension175~MorPidfeafu .. .. . ...~17{)ONEO!vers.eemsto ge~weU ·2Q2 LJ Painfu!menses177 C1Forgetfuiness ... ..•..... •••203 r·l Depressed feelings

. 17BLjlildigeStiOn . . before menstruatiOn179UPoorappetite .......~J.. ..2D4OMenstruati.on. excessive

·180 L Cr<1vlngforsw€ets

..•.. ·~1·.••.:8.:·3}8D'; •.· • •.•~N••·OU._ISS.~eU.·.·s,ae~:.nrti·~.".:n.··!.ety.• ri:. 9s.·.·... 0.f dread if)5.[J::n:J~:::,.."y ..• 2(}6 [JM~mrtruatetoo frequently

-r.: 184UAq<>usnchaUJic:iriations . ·.2·0·.7.··.•r::l...•.....••u.·a .:·g.j·.n.·.al.·... ·d··I·~•.•••.....a.".ge·. .18s0Tendenc;y tOGfy· . Li v, ""-4' '-. .withoUt reason . • 2(}8[jHystereclomy/ovaries

186 []HaitisooarSeandlor removed·thinning ?!19 [JMenopauSalhotflashes

187 ~iweaki1eS$ . . . .- 21.•.0:.'. 1.Mensesscanh' or rnis..sed1$8 nFatigue ... ... '.,18~ TlSkin Sen$itive 10 touCh 211 0Acne, worse at menses

. 190<[]Tendency toward I1rVes212 LJ Depression of longstanding191.0 N~r'Votisness192 .EJHeadache

·193 LJlh50mriia·j94.0Anxiety

.. >195 OArlo(exia ....196 [Jtnciliility toconcentrate: •

•• .confUsionr-:-1FiarRierlt stlJffy·.· nose' s..inus.L_:J ." •.••.~. ... .,

Tnfections19~.DAilerIDrtosomefoocts.·

.•199·.DLoosejoints. . .

IMPORTANTTO THE FlATIEt;JT: Please fist belowthefiveimainphysicaicomplaints you have in .orderof ~eir imPortance .

,.....:-...,--'--.---,----.,.-----------_ .._-

. . .,.;. ... .... .

.: ....••••..••.•.••.•. .••••.•• .: .••... (TO BE COMPLETED BY DOCTOR)... ...... .. -- -. ..

PosturalskJ6d Pressure: ..Recumbent·· Stai1ding ..i:.:_-'-,-_.,.--..,..___ Pulse-...O-,,'---'-_--'----'

Hema:.tomblSftx Urine readings: ••pH·· Albumin per cent .'--'-'- .Gluoosepercent _.. _

OCCUItB/OOlf pRof SaliVa.~.~_-,-~__ pHof Stool sped men __ -'--___ Wei9ht._~ __ ~_

BARNES THYROID TEST Yo~can delhi !oiloWiogtest at home to setilf you mayhave aiunci;6n'. This test was deve1bpedby Dr. BrodaBarr'Ies. M~[).andjsa m~asuiernentolthe aJIO'.vthyroi.d, US~an. ~Phermometei oradig!talone. \'ihen you use a

underarm teITI~atUre to oetermmeliypoand hyperthyrciidstates. The teSt is <:90. digilaJ one, Ptacethe .piobe·ul){leryour:iirm !.Qr5 minuti=$ ·ltiEiriturn~f·ductedbylhii paliEinf in (he a.rn, beforeleaiiingbed· -With· the lemperature being .marn;ne on; continue on for an .adctiiJonat s minutes. Wnen using a reg-laken for 10 minutes: The: iestis invatidated if 100 pat(E;nt expends any energy prioi: ularone. shake down the nil)ht b!iiore. .loleking tliEHeSt-¥"iOguptonmyreasoo, shaking down memermometer; etc.jt Date: Temperature: ..__ ~ _!iiimPortlinllh<il.the .tei;t:!,eCoridCJCtedfure:<aclly 10 minutes, makingthEi prior posi-. -~~-~~- -tfuning of OOihthe thermoineter anda ctocklmpoetarn, •. • . . Date: Temperature: -'-----, _

... PRECMENSESF£MALESANDMeNOpAUSM...FEMALES bate: Temperature:. . . Any two~ys~:irlngiherhonu-i -----~

·FEMALEsHA.VlNG MeNsrtn.iALcYCLES· Date: Temperature: __ ~ _•The 2"' ;md~~da~: of !low O.R,.;;,! 5 daySina row Date: Temperature: --'-'

AIlY2diiys~~ me mOllth. . Date: . Temperature: ~~-.'-..-_-Date: Temperature:

!?PSTAND_-,- __ ~ __.. PULSE STAND .---,~ _

_ ~ __ ~~ __ BLOOOTYPE _-'---'--.:......-~-'--