Anthony Animal Clinic

Symptom Survey

Restricted to Professional Use


Patient's Name
Date
E-Mail
Phone
INSTRUCTIONS:    Use "1" for mild symptoms (occurs once or twice a year), use "2" for moderate symptoms (occurs several times a year), and use "3" for severe symptoms (you are aware of it almost constantly). Leave box 0 if it does not apply to you.

Group 1 - Sympathetic Overload

 1 Acid foods upset  8 Gag easily  15 Appetite reduced
 2 Get chilled, often  9 Unable to relax; startles easily  16 Cold sweats often
 3 "Lump" in throat  10 Extremities cold, clammy  17 Fever easily raised
 4 Dry mouth-eyes-nose  11 Strong light irritates  18 Neuralgia-like pains
 5 Pulse speeds after meals  12 Urine amount reduced  19 Staring, blinks little
 6 Keyed up-fail to calm  13 Heart pounds after retiring  20 Sour stomach frequent
 7 Cuts heal slowly  14 "Nervous" stomach         

Group 2 - Parasympathetic Overload

 21 Joint stiffness after arising  28 Always seems hungry; feels "lightheaded" often  35 Difficulty swallowing
 22 Muscle-leg-toe cramps at night  29 Digestion rapid  36 Constipation, diarrhea alternating
 23 "Butterfly" stomach, cramps  30 Vomiting frequent  37 "Slow starter"
 24 Eyes or nose watery  31 Hoarseness frequent  38 Get "chilled" infrequently
 25 Eyes blink often  32 Breathing irregular  39 Perspire easily
 26 Eyelids swollen, puffy  33 Pulse slow; feels "irregular"  40 Circulation poor, sensitive to cold
 27 Indigestion soon after meals  34 Gagging reflex slow  41 Subject to colds, asthma, bronchitis

Group 3 - Blood Sugar Stress

 42 Eat when nervous  47 Fatigue, eating relieves  52 Awaken after few hours sleep-hard to get back to sleep
 43 Excessive appetite  48 "Lightheaded" if meals delayed  53 Crave cand or coffee in afternoons
 44 Hungry between meals  49 Heart palpitates of meals missed or delayed  54 Moods of depression - "blues" or melancholy
 45 Irritable before meals  50 Afternoon headaches  55 Abnormal craving for sweets or snacks
 46 Get "shaky" if hungry  51 Overeating sweets upsets         

Group 4 - Cardiovascular (Stress)

 56 Hands and feet go to sleep easily, numbness  62 Afternoon "yawner"  68 Bruise easily, "black/blue" spots
 57 Sigh frequently, "air hunger"  63 Get "drowsy" often  69 Tendency to anemia
 58 Aware of "breathing heavy"  64 Swollen ankles worse at nught  70 "Nose bleeds" frequent
 59 High altitude discomfort  65 Muscle cramps, worse during exercise; get "charley horses"  71 Noises in head or "ringing in ears"
 60 Opens windows in closed room  66 Shortness of breath on exertion  72 Tension under the breastbone, or feeling of "lightness", worse on exertion
 61 Susceptible to colds and fevers  67 Dull pain in chest or radiating into left arm, worse on exertion         

Group 5 - Liver & Gallbladder

 73 Dizziness  82 Worrier, feels insecure  91 Sneezing attacks
 74 Dry skin  83 Feeling queasy; headache over eyes  92 Dreaming, nightmare type bad dreams
 75 Burning feet  84 Greasy foods upset  93 Bad breath (halitosis)
 76 Blurred vision  85 Stools light-colored  94 Milk products cause distress
 77 Itching skin and feet  86 Skin peels on foot soles  95 Sensitive to hot weather
 78 Excessive falling hair  87 Pain between shoulder blades  96 Burning or itching anus
 79 Frequent skin rashes  88 Use laxitives  97 Crave sweets
 80 Bitter, metallic taste in mouth in mornings  89 Stools alternate from soft to watery         
 81 Bowel movements painful or difficult  90 History of gallbladder attacks or gallstones         

Group 6 - Digestive Stress

 98 Loss of taste for meat  101 Coated tongue  104 Mucus colitis or "irritable bowel"
 99 Lower bowel gas several hours after eating  102 Pass large amounts of foul smelling gas  105 Gas shortly after eating
 100 Burning somach sensations, eating relieves  103 Indigestion 1/2 - 1 hour after eating; may be up to 3 - 4 hours  106 Stomach "bloating" after eating

Group 7A - Hyperthyroid

 107 Insomnia  112 Flush easily  117 Increased appetite without weight gain
 108 Nervousness  113 Night sweats  118 Pulse fast at rest
 109 Can't gain weight  114 Thin, moist skin  119 Eyelids and face twitch
 110 Intolerance to heat  115 Inward trembling  120 Irritable and restless
 111 Highly emotional  116 Heart palpitates  121 Can't work under pressure

Group 7B - Hypothyroid

 122 Increase in weight  127 Sensitive to cold  132 Headaches upon arising wear off during day
 123 Decrease in appetite  128 Dry or scaly skin  133 Slow pulse, below 65
 124 Fatigue easily  129 Constipation  134 Frequency of urination
 125 Ringing in ears  130 Mental sluggishness  135 Impaired hearing
 126 Sleepy during day  131 Hair course, falls out  136 Reduced initiative

Group 7C

 137 Failing memory  139 Increased sex drive  141 Decreased sugar tolerance
 138 Low blood pressure  140 Headaches, "splitting or rending" type         

Group 7D

 142 Abnormal thirst  145 Sex drive reduced or lacking  148 Women: menstrual disorders
 143 Bloating of abdomen  146 Tendency to ulcers, colitis  149 Young girls; lack of menstrual functionn
 144 Weight gain around hips or waist  147 Increased sugar tolerance         

Group 7E

 150 Dizziness  153 Increased blood pressure  156 Masculine tendencies (female)
 151 Headaches  154 Hair growth on face or body (female)         
 152 Hot flashes  155 Sugar in urine (not diabetes)         

Group 7F

 157 Weakness, dizziness  163 Perspiration increase  169 Allergies - tendencies to asthma
 158 Chronic fatigue  164 Bowel disorders  170 Weakness after colds, influenza
 159 Low blood pressure  165 Poor circulation  171 Exhaustion - muscular and nervous
 160 Nails weak, ridged  166 Swollen ankles  172 Respiratory disorders
 161 Tendency to hives  167 Crave salt         
 162 Arthritic tendencies  168 Brown spots or bronzing of skin         

Female Hormone Imbalance

 173 Very easily fatigued  178 Painful breasts  183 Menses scanty or missed
 174 Premenstrual tension  179 Menstruate too frequently  184 Acne, worse at menses
 175 Painful menses  180 Vaginal discharge  185 Depression of long standing
 176 Depressed feelings before menstration  181 Hysterectomy/ovaries removed         
 177 Menstruation excessive and prolonged  182 Menopausal hot flashes         

Male Only

 186 Prostate trouble  190 Pain on inside of legs or heels  194 Tire too easily
 187 Urination difficult or dribbling  191 Feeling of incomplete bowel movement  195 Avoids activity
 188 Night urination frequent  192 Lack of energy  196 Leg nervousness at night
 189 Depression  193 Migrating aches and pains  197 Diminished sex drive

Important

To the Patient:
Please list below the five main health complaints you have in order of their importance:

1.    
2.    
3.    
4.    
5.