Symptoms Survey

Instructions

Select the number that applies to you. If a symptom does not apply, select N/A for that symptom. The Next button to proceed to the following section will appear when each symptom has been addressed.

N/A	NOT APPLICABLE
1	MILD symptom (occurs rarely)
2	MODERATE symptom (occurs several times a month)
3	SEVERE symptom (occurs almost constantly)

Group 1

Acid foods upset

N/A 1 2 3

Get chilled often

N/A 1 2 3

"Lump" in throat

N/A 1 2 3

Dry mouth, eyes, nose

N/A 1 2 3

Pulse speeds after meal

N/A 1 2 3

Keyed up, fail to calm

N/A 1 2 3

Gag occasionally

N/A 1 2 3

Unable to relax, startle easily

N/A 1 2 3

Extremities cold, clammy

N/A 1 2 3

Strong light irritates

N/A 1 2 3

Occasionally weak urine flow

N/A 1 2 3

Heart pounds after retiring

N/A 1 2 3

"Nervous" stomach

N/A 1 2 3

Appetite reduced occasionally

N/A 1 2 3

Cold sweats often

N/A 1 2 3

Get heated easily

N/A 1 2 3

Nerve discomfort

N/A 1 2 3

Staring, blink little

N/A 1 2 3

Sour stomach frequent

N/A 1 2 3

Group 2

Joint stiffness after arising

N/A 1 2 3

Muscle, leg, toe cramps at night

N/A 1 2 3

"Butterfly" stomach, cramps

N/A 1 2 3

Eyes or nose watery

N/A 1 2 3

Eyes blink often

N/A 1 2 3

Eyelids swollen, puffy

N/A 1 2 3

Indigestion soon after meals

N/A 1 2 3

Always seem hungry, feel "lightheaded" often

N/A 1 2 3

Digestion rapid

N/A 1 2 3

Vomit occasionally

N/A 1 2 3

Hoarseness frequent

N/A 1 2 3

Uneven breathing

N/A 1 2 3

Pulse slow

N/A 1 2 3

Gagging reflex slow

N/A 1 2 3

Difficulty swallowing

N/A 1 2 3

Temporary constipation or diarrhea

N/A 1 2 3

"Slow starter"

N/A 1 2 3

Get "chilled"

N/A 1 2 3

Perspire easily

N/A 1 2 3

Sensitive to cold

N/A 1 2 3

Upper respiratory challenges

N/A 1 2 3

Group 3

Eat when nervous

N/A 1 2 3

Excessive appetite

N/A 1 2 3

Hungry between meals

N/A 1 2 3

Irritable before meals

N/A 1 2 3

Get "shaky" if hungry

N/A 1 2 3

Fatique, eating relieves

N/A 1 2 3

"Lightheaded" if meals delayed

N/A 1 2 3

Heart palpitates if meals are missed or delayed

N/A 1 2 3

Fatigue in afternoon

N/A 1 2 3

Overeating sweets upsets

N/A 1 2 3

Awaken after few hours sleep, hard to get back to sleep

N/A 1 2 3

Crave candy or coffee in afternoon

N/A 1 2 3

Moods of "blues" or melancholy

N/A 1 2 3

Craving for sweets or snacks

N/A 1 2 3

Group 4

Hands and feet go to sleep easily, numbness

N/A 1 2 3

Sigh frequently, "air hunger"

N/A 1 2 3

Aware of "breathing heavily"

N/A 1 2 3

High-altitude discomfort

N/A 1 2 3

Open windows in closed room

N/A 1 2 3

Immune system challenges

N/A 1 2 3

Afternoon "yawner"

N/A 1 2 3

Get "drowsy" often

N/A 1 2 3

Swollen ankles worse at night

N/A 1 2 3

Muscle cramps, worse during exercise; get "charley horse"

N/A 1 2 3

Difficulty catching breath, especially during exercise

N/A 1 2 3

Tightness or pressure in chest, worse on exertion

N/A 1 2 3

Skin discolors easily after impact

N/A 1 2 3

Tendency to anemia

N/A 1 2 3

Noises in head or "ringing in ears"

N/A 1 2 3

Fatigue upon exertion

N/A 1 2 3

Group 5

Dizziness

N/A 1 2 3

Dry skin

N/A 1 2 3

Burning feet

N/A 1 2 3

Blurred vision

N/A 1 2 3

Itching skin and feet

N/A 1 2 3

Hair loss

N/A 1 2 3

Occasional skin rashes

N/A 1 2 3

Bitter, metallic taste in mouth in morning

N/A 1 2 3

Occasional constipation

N/A 1 2 3

Worrier, feels insecure

N/A 1 2 3

Nausea occasionally after eating

N/A 1 2 3

Greasy foods upset

N/A 1 2 3

Stools light-colored

N/A 1 2 3

Skin peels on foot soles

N/A 1 2 3

Discomfort between shoulder blades

N/A 1 2 3

Occasional laxative use

N/A 1 2 3

Stools alternate from soft to watery

N/A 1 2 3

Sneezing attacks

N/A 1 2 3

Dreaming, nightmare-type bad dreams

N/A 1 2 3

Bad breath (halitosis)

N/A 1 2 3

Milk products cause upset

N/A 1 2 3

Sensitive to hot weather

N/A 1 2 3

Burning or itching anus

N/A 1 2 3

Crave sweets

N/A 1 2 3

Group 6

Loss of taste for meat

N/A 1 2 3

Lower bowel gas several hours after eating

N/A 1 2 3

Burning stomach sensations, eating relieves

N/A 1 2 3

Coated tongue

N/A 1 2 3

Pass large amounts of foul-smelling gas

N/A 1 2 3

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

N/A 1 2 3

Watery or loose stool

N/A 1 2 3

Gas shortly after eating

N/A 1 2 3

Stomach "bloating"

N/A 1 2 3

Group 7A

Difficulty sleeping

N/A 1 2 3

On edge

N/A 1 2 3

Can't gain weight

N/A 1 2 3

Intolerance to heat

N/A 1 2 3

Highly emotional

N/A 1 2 3

Flush easily

N/A 1 2 3

Night sweats

N/A 1 2 3

Thin, moist skin

N/A 1 2 3

Inward trembling

N/A 1 2 3

Heart races

N/A 1 2 3

Increased appetite without weight gain

N/A 1 2 3

Pulse fast at rest

N/A 1 2 3

Eyelids and face twitch

N/A 1 2 3

Irritable and restless

N/A 1 2 3

Can't work under pressure

N/A 1 2 3

Group 7B

Increase in weight

N/A 1 2 3

Decrease in appetite

N/A 1 2 3

Fatigue easily

N/A 1 2 3

Ringing in ears

N/A 1 2 3

Sleepy during day

N/A 1 2 3

Sensitive to cold

N/A 1 2 3

Dry or scaly skin

N/A 1 2 3

Temporary constipation

N/A 1 2 3

Mental sluggishness

N/A 1 2 3

Hair coarse, falls out

N/A 1 2 3

Tension in head upon arising wears off during day

N/A 1 2 3

Slow pulse below 65

N/A 1 2 3

Changing urinary function

N/A 1 2 3

Sounds appear diminished

N/A 1 2 3

Reduced initiative

N/A 1 2 3

Group 7C

Failing memory with age

N/A 1 2 3

Increased sex drive

N/A 1 2 3

Episodes of tension in head

N/A 1 2 3

Decreased sugar tolerance

N/A 1 2 3

Group 7D

Abnormal thirst

N/A 1 2 3

Bloating of abdomen

N/A 1 2 3

Weight gain around hips or waist

N/A 1 2 3

Sex drive reduced or lacking

N/A 1 2 3

Tendency for stomach issues

N/A 1 2 3

Immune system challenges

N/A 1 2 3

Menstrual disorders

N/A 1 2 3

Group 7E

Dizziness

N/A 1 2 3

Headaches

N/A 1 2 3

Hot flashes

N/A 1 2 3

Hair growth on face or body (female)

N/A 1 2 3

Sugar in urine (not diabetes)

N/A 1 2 3

Masculine tendencies (female)

N/A 1 2 3

Group 7F

Weakness, dizziness

N/A 1 2 3

Tired throughout day

N/A 1 2 3

Nails weak, ridged

N/A 1 2 3

Sensitive skin

N/A 1 2 3

Stiff joints

N/A 1 2 3

Perspiration increase

N/A 1 2 3

Bowel discomfort

N/A 1 2 3

Poor circulation

N/A 1 2 3

Swollen ankles

N/A 1 2 3

Crave salt

N/A 1 2 3

Areas of skin darkening

N/A 1 2 3

Upper respiratory sensitivity

N/A 1 2 3

Tiredness

N/A 1 2 3

Breathing challenges

N/A 1 2 3

Group 8

Muscle weakness

N/A 1 2 3

Lack of stamina

N/A 1 2 3

Drowsiness after eating

N/A 1 2 3

Muscular soreness

N/A 1 2 3

Heart races

N/A 1 2 3

Hyperirritable

N/A 1 2 3

Feeling of a band around head

N/A 1 2 3

Melancholia (feeling of sadness)

N/A 1 2 3

Swelling of ankles

N/A 1 2 3

Change in urinary function

N/A 1 2 3

Tendency to consume sweets/carbohydrates

N/A 1 2 3

Muscle spasms

N/A 1 2 3

Blurred vision

N/A 1 2 3

Involuntary muscle action

N/A 1 2 3

Numbness

N/A 1 2 3

Night sweats

N/A 1 2 3

Rapid digestion

N/A 1 2 3

Sensitivity to noise

N/A 1 2 3

Redness of palms of hands and bottom of feet

N/A 1 2 3

Visible veins on chest and abdomen

N/A 1 2 3

Hemorrhoids

N/A 1 2 3

Apprehension (feeling that something bad is going to happen)

N/A 1 2 3

Nervousness causing loss of appetite

N/A 1 2 3

Nervousness with indigestion

N/A 1 2 3

Gastritis

N/A 1 2 3

Forgetfulness

N/A 1 2 3

Thinning hair

N/A 1 2 3

Female Only

Very easily fatigued

N/A 1 2 3

Premenstrual tension

N/A 1 2 3

Menses more painful than usual

N/A 1 2 3

Depressed feelings before menstruation

N/A 1 2 3

Painful breasts during menses

N/A 1 2 3

Menstruate too frequently

N/A 1 2 3

Hysterectomy/ovaries removed

N/A 1 2 3

Menopausal hot flashes

N/A 1 2 3

Menses scanty or missed

N/A 1 2 3

Acne, worse at menses

N/A 1 2 3

Male Only

Less involved in exercise/social activites

N/A 1 2 3

Difficult to postpone urination

N/A 1 2 3

Weak urinary stream

N/A 1 2 3

Feeling of "blues" or melancholy

N/A 1 2 3

Feeling of incomplete bowel evacuation

N/A 1 2 3

Lack of energy

N/A 1 2 3

Muscles in arms and legs seem softer/smaller

N/A 1 2 3

Tire too easily

N/A 1 2 3

Avoid activity

N/A 1 2 3

Leg nervousness at night

N/A 1 2 3

Diminished sex drive

N/A 1 2 3

IMPORTANT | Please list below the five main physical complaints you have in order of their importance.

Please do not submit any Protected Health Information (PHI).

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Address

115 Republic Ave
Joliet, IL 60435

Contact Information (815) 207-7463

(815) 483-2071

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Contact Us

Office Hours

Monday

9:00 am - 5:00 pm

Tuesday

9:00 am - 7:00 pm

Wednesday

Closed

Thursday

9:00 am - 7:00 pm

Friday

9:00 am - 12:00 pm

Saturday

Closed

Sunday

Closed

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Instructions

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7A

Group 7B

Group 7C

Group 7D

Group 7E

Group 7F

Group 8

Female Only

Male Only

Location

Find us on the map

Contact Us

Office Hours