Home

www.victorychiropractic.com

Shopping Cart (0)

Symptom Survey

Home > Symptom Survey

Symptom Survey

First Name *

Last Name *

Email address *

Phone *

Vegetarian *

YESNO

INSTRUCTIONS: Check the number that applies to you in each of the 8 groups using the following guide.The Symptom Survey Analysis provides a way to assess your individual supplement needs and possible health issues

GUIDE

0 - Symptom does not apply to me1 - Mild (symptoms occur once or twice a month.)2 - Moderate (Symptoms occur several times a month.)3 - Severe (You are aware of the symptoms almost constantly.)

GROUP 1

Acid foods upset *

0123

Body gets chilled often *

0123

Feel "lump" in your throat *

0123

Dry mouth-eyes-nose *

0123

Pulse speeds after meals *

0123

Get keyed up - fail to calm down *

0123

Cuts heal slowly *

0123

Gag easily *

0123

Unable to relax - startles easily *

0123

Extremities cold, clammy *

0123

Strong light irritates you *

0123

Urine amount reduced *

0123

Heart pounds after retiring/resting *

0123

"Nervous" stomach *

0123

Appetite reduced *

0123

Get cold sweats often *

0123

Fever easily raised *

0123

Nerve pains *

0123

Stare often, blink little *

0123

Sour stomach frequent *

0123

GROUP 2

Joint stiffness after rising *

0123

Muscle-leg-toe cramps at night *

0123

"Butterfly" stomach, cramps *

0123

Eyes, nose watery *

0123

Eyes blink often *

0123

Eyelids swollen or puffy *

0123

Indigestion soon after meals *

0123

Always hungry; feel lightheaded often *

0123

Rapid digestion *

0123

Frequent vomiting *

0123

Frequent hoarseness, sore throat *

0123

Irregular breathing *

0123

Pulse feels slow or irregular *

0123

Gagging reflex slow *

0123

Difficulty swallowing *

0123

Alternating constipation / diarrhea *

0123

"Slow starter", trouble to get moving *

0123

Get chilled infrequently *

0123

Perspire easily *

0123

Poor circulation, sensitive to cold *

0123

Subject to colds, asthma, bronchitis *

0123

GROUP 3

Eat when nervous *

0123

Excessive appetite *

0123

Hungry between meals *

0123

Irritable before eating foods *

0123

Get 'shaky' when hungry *

0123

Eating relieves fatigue *

0123

"Lightheaded" if meals delayed *

0123

Heart palpitates if meals are missed/delayed *

0123

Get afternoon headaches *

0123

Overeating sweets upsets body *

0123

Awaken after a few hours of sleep - hard to get back to sleep *

0123

Crave candy or coffee in the afternoon *

0123

Moods of depression, feeling blue, or melancholy *

0123

Abnormal craving for sweets or snacks *

0123

GROUP 4

Hands and feet go to sleep easily, numbness *

0123

Sigh frequently, deep heavy breaths *

0123

Aware of heavy breathing *

0123

High altitude discomfort *

0123

Opens windows in closed rooms *

0123

Susceptible to colds and fevers *

0123

Afternoon yawner *

0123

Get drowsy often *

0123

Swollen ankles worse at night *

0123

Muscle cramp, worse during exercise, get "charley horses" *

0123

Shortness of breath on exertion *

0123

Dull pain in chest or radiating into left arm, worse on exertion *

0123

Bruise easily, "black and blue" spots *

0123

Anemic tendencies *

0123

Frequent nose bleeds *

0123

Noises in head or ringing in ears *

0123

Tension under the breastbone, or feeling tightness worse on exertion *

0123

GROUP 5

Dizziness *

0123

Dry skin *

0123

Burning feet *

0123

Blurred vision *

0123

Itching skin and feet *

0123

Excessive hair falling out *

0123

Frequent rashes on skin *

0123

Bitter, metallic taste in mouth in mornings *

0123

Bowel movements painful or difficult *

0123

Worrier, feels insecure *

0123

Feeling queasy; headache over or beind eyes *

0123

Greasy food upsets stomach *

0123

Stools light colored *

0123

Skin peels on foot soles *

0123

Pain between shoulder blades *

0123

Use laxatives *

0123

Stools alternate from soft to watery *

0123

History of gallbladder attacks, gallstones *

0123

Sneezing attacks *

0123

Dreaming, nightmare type bad dreams *

0123

Bad breath, halitosis *

0123

Milk products cause distress *

0123

Sensitive to hot weather *

0123

Burning or itching anus *

0123

Crave sweets *

0123

GROUP 6

Loss of taste for meat *

0123

Lower bowel gas several hours after eating *

0123

Burning stomach sensations relieved by eating *

0123

Coated tongue *

0123

Pass large amounts of foul-smelling gas *

0123

Indigestion 1/2 - 1 hour after eating, may last up to 3 - 4 hours *

0123

Mucous colitis or "irritable bowel" *

0123

Gas shortly after eating *

0123

Stomach bloating after eating *

0123

GROUP 7 - A

Insomnia *

0123

Nervousness *

0123

Can't gain weight *

0123

Intolerance to heat *

0123

Highly emotional *

0123

Get flush easily *

0123

Night sweats *

0123

Thin, moist skin *

0123

Inward trembling *

0123

Heart palpitates *

0123

Increased appetite without weight gain *

0123

Pulse fast when resting *

0123

Eyelids and face twitch *

0123

Irritable, restless *

0123

Unable to work under pressure *

0123

GROUP 7 - B

Increase in weight *

0123

Decreased appetite *

0123

Fatigue easily *

0123

Ringing in ears *

0123

Get sleepy during the day *

0123

Sensitive to cold *

0123

Dry or scaly skin *

0123

Constipation *

0123

Sluggish mental capacity *

0123

Hair course, falls out frequenty *

0123

Headaches upon rising wear off during the day *

0123

Slow pulse, below 65bpm *

0123

Frequent urination *

0123

Impaired hearing *

0123

Reduced initiative *

0123

GROUP 7 - C

Failing memory *

0123

Low blood pressure *

0123

Increased sex drive *

0123

Headaches "splitting or rending" type *

0123

Decreased sugar tolerance *

0123

GROUP 7 - D

Abnormal thirst *

0123

Bloating of abdomen *

0123

Weight gain around hips or waist *

0123

Sex drive reduced or lacking *

0123

Tendency to ulcers, mouth sores *

0123

Increased sugar tolerance *

0123

Women: menstrual disorders *

0123

Young girls: lack of menstrual function *

0123

GROUP 7 - E

Dizziness *

0123

Headaches *

0123

Hot flashes *

0123

Increased blood pressure *

0123

Hair growth on face or body (females) *

0123

Sugar in urine (not diabetes) *

0123

Masculine tendencies (female) *

0123

GROUP 7 - F

Weakness or dizziness *

0123

Chronic fatigue *

0123

Low blood pressure *

0123

Nails weak, rigid *

0123

Tendency to hives *

0123

Arthritic tendencies *

0123

Increased perspiration *

0123

Bowel disorders *

0123

Poor circulation *

0123

Swollen ankles *

0123

Crave salt *

0123

Brown spots or bronzing on skin *

0123

Allergies - tendency to asthma *

0123

Weakness after colds, influenza *

0123

Exhaustion - muscular and nervous *

0123

Respiratory disorders *

0123

GROUP 8

Apprehension *

0123

Irritability *

0123

Morbid fears *

0123

Never seems to get well *

0123

Forgetfullness *

0123

Indigestion *

0123

Poor appetite *

0123

Craving for sweets *

0123

Muscular soreness *

0123

Depression, feelings of dread *

0123

Noise sensitivity *

0123

Acoustic hallucinations *

0123

Tendency to cry without reason *

0123

Hair is course and/or thinning *

0123

Weakness *

0123

Fatigue *

0123

Skin sensitive to touch *

0123

Tendency toward hives *

0123

Nervousness *

0123

Headache *

0123

Insomnia *

0123

Anxiety *

0123

Anorexia *

0123

Inability to concentrate; confusion *

0123

Frequent stuffy nose; sinus infections *

0123

Allergy response to some foods *

0123

Loose joints *

0123

FEMALE ONLY (men - select 0 for all of the following)

Very easily fatigued *

0123

Premenstrual tension, frustration *

0123

Painful menses *

0123

Depressed feelings *

0123

Menstruation excessive and prolonged *

0123

Painful breasts *

0123

Menstruate too frequent *

0123

Vaginal discharge *

0123

Hysterectomy/ovaries removed *

0123

Menopausal hot flashes *

0123

Menses irregular or missed *

0123

Acne, worse at menses *

0123

Long standing depression *

0123

MALE ONLY (females - select 0 for all of the following)

Prostate trouble *

0123

Urination difficult or dribbling *

0123

Night urination frequent *

0123

Depression *

0123

Pain on inside of legs or heels *

0123

Feeling of incomplete bowel evacuation *

0123

Lack of energy *

0123

Migrating aches/pains *

0123

Tire too easily *

0123

Avoids activity *

0123

Leg nervousness at night/restless leg *

0123

Drop in sex drive *

0123

IMPORTANT

TO THE PATIENT: Please list below the five main physical complaints you have in order of their importance

1. *

2. *

3. *

4. *

5. *

BARNES THYROID TEST

This test was developed by Dr. Broda Barnes, MD and is a measurement of the underarm temperature to determine hypo and hyperthyroid states. The test is conducted by the patient in the a.m. before leaving bed - with the temperature being taken for 10 minutes. The test is invalidated if the patient expends any energy prior to taking the test - getting up for any reason, s

PRE-MENSES FEMALES AND MENOPAUSAL FEMALES may test any 2 days during the month.

FEMALES HAVING MENSTRUAL CYCLES must test the 2nd and 3rd day of the flow OR any 5 days in a row.

MALES may test any 2 days during the month.

You can do the Barnes Thyroid test at home to see if you may have a functional low thyroid. Use an oral thermometer or a digital one. When you use a digital one, place the probe under your arm for 5 minutes then turn the machine on; continue for an additional 5 minutes. When using a regular one, shake down the thermometer the night before.

Date and Temperature

ADDITIONAL INFORMATION

Answers to the following questions can help obtain a more accurate personalized supplementation program for you. However, they are not required.

Blood Pressure - sitting

Blood Pressure - standing

Pulse - sitting

Pulse - standing

Blood type

Age

Enter the verification code in the box below.

Verification Code: *

Top

Mon	8 - 2	4 - 6
Tue	Closed	4 - 6
Wed	8 - 2	4 - 6
Thu	8 - 2	4 - 6
Fri	8 - 2	Closed
Sat	9 - 12	Closed
Sun	Closed

Call Us:
817-251-6767 Request
Appt.

Newsletter Sign Up

3D Spine Simulator

Launch 3D Spine Simulator

Symptom Survey

Symptom Survey

GROUP 1

GROUP 2

GROUP 3

GROUP 4

GROUP 5

GROUP 6

GROUP 7 - A

GROUP 7 - B

GROUP 7 - C

GROUP 7 - D

GROUP 7 - E

GROUP 7 - F

GROUP 8

FEMALE ONLY (men - select 0 for all of the following)

MALE ONLY (females - select 0 for all of the following)

IMPORTANT

BARNES THYROID TEST

ADDITIONAL INFORMATION

Newsletter Sign Up

3D Spine Simulator

Community Content