Patient Forms

Acid foods upset

Get chilled, often

"Lump" in throat

Dry mouth-eyes-nose

Pulse speeds after meal

Keyed up — fail to calm

Cuts heal slowly

Gag easily

Unable to relax; startles easily

Extremities cold, clammy

Strong light irritates

Urine amount reduced

Heart pounds after retiring

“Nervous" stomach

Appetite reduced

Cold sweats often

Fever easily raise

Neuralgia-like pains

Staring, blinks little

Sour stomach frequent

Joint stiffness after arising

Muscle-leg-toe cramps at night

"Butterfly" stomach, cramps

Eyes or nose watery

Eyes blink often

Eyelids swollen, puffy

Indigestion soon after meals

Always seems hungry feels "lightheaded" often

Digestion rapid

Digestion rapid

Vomiting frequent

Hoarseness frequent

Breathing irregular

Pulse slow; feels "irregular"

Gagging reflex slow

Difficulty swallowing

Constipation, diarrhea alternating

“Slow starter"

Get "chilled" infrequently

Perspire easily

Circulation poor, sensitive to cold

Subject to colds, asthma, bronchitis

Eat when nervous

Excessive appetite

Hungry between meals

Irritable before meal

Get "shaky" if hungry

Fatigue, eating relieves

"Lightheaded" if meals delayed

Heart palpitates if meals missed or delayed

Afternoon headaches

Overeating sweets upsets

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

Hands and feet go to sleep easily, numbness

Sigh frequently, “air hunger'

Aware of "breathing heavily"

High altitude discomfort

Opens 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 and blue" spots

Tendency to anemia

"Nose bleeds” frequent

Noises in head, or "ringing in ears"

Tension under the breastbone, or feeling of "tightness", worse on exertion

Loss of taste for meat

Lower bowelgas several hours after eating

Burning stomach sensations, eating relieves

Coated tongue

Pass large amounts of foul-smelling gas

Indigestion 1/2-1 hour after eating; may be up to 3-4 hrs.

Mucouscolitis or "irritable bowel"

Gas shortly after eating

Stomach "bloating" after eating

(A)

Insomnia

Nervousness

Can’t gain weight

intolerance to heat

Highly emotional

Flush easily

Night sweats

Thin, moist skin

Inward trembling

Heart palpitates

Increased appetite without weight gain

Pulse fast at rest

Eyelids and face twitch

Irritable and restless

Can't work under pressure

(B)

Increase in weight

Decrease in appetite

Fatigue easily

Ringing in ears

Sleepy during day

Sensitive to cold

Dry or scaly skin

Constipation

Mental sluggishness

Hair coarse, falls out

Headaches upon arising wearoff during day

Slow pulse, below 65

Frequency of urination

impaired hearing

Reduced initiative

(C)

Failing memory

Low blood pressure

Increased sex drive

Headaches,“splitting or rending” type

Decreased sugar tolerance

(D)

Abnormal thirst

Bloating of abdomen

Weight gain around hips or waist

Sex drive reduced or lacking

Tendency to ulcers, colitis

Increased sugar tolerance

Women: menstrual disorders

Younggirls: lack of menstrual function

(E)

Dizziness

Headaches

Hot flashes

Increased blood pressure

Hair growth on face or body (female)

Sugar in urine (not diabetes)

Masculine tendencies (female)

(F)

Weakness, dizziness

Chronic fatigue

Low blood pressure

Nails weak, ridged

Tendency to 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, influenza

Exhaustion - muscular and nervous

Respiratory disorders