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Symptom Survey

MILD = occurs rarely, MODERATE = occurs several times a month, SEVERE = constant

A. Sympathetic Dominance

Acid food upsets*

Get chilled often*

"Lump" in throat*

Dry-mouth-eyes-nose*

Pulse speeds after meals*

Keyed up - fail to calm*

Cuts heal slowly*

Gag easily*

Unable to relax, startle easily*

Extremities, cold clammy*

Strong light irritates*

Urine amount reduced*

Heart pounds after retiring*

"Nervous" stomach*

Appetite reduced*

Cold sweats often*

Fever easily raised*

Neuralgia-like pains*

Staring, blinks little*

Sour stomach frequently*

Section A Total

B. Parasympathetic Dominance

Joints stiff 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 hungry; "lightheaded" often*

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*

Section B Total

C. Sugar Handling

Eat when nervous*

Excessive appetite*

Hungry between meals*

Irritable before meals*

Get "shaky" if hungry*

Fatigue, relieved by eating*

"Lightheaded" if meal is delayed*

Heart palpitations if meal is delayed*

Afternoon headaches*

Overeating sweets upsets stomach*

Sleeping few hours; difficulty falling asleep*

Crave candy or coffee in afternoons*

Depression moods: "blues"/melancholy*

Abnormal craving for sweets/snacks*

Section C Total

D. Cardiovascular

Hands/feet go to sleep, numbness*

Sigh frequently, "air hunger"*

Aware of "breathing heavily"*

High altitude discomfort*

Need to open windows in closed room*

Susceptible to colds and fevers*

Afternoon "yawner"*

Get "drowsy" often*

Swollen ankles worse at night*

Muscle cramps worse in exercise/"charley horses"*

Shortness of breath worse in exertion*

Dull pain in chest/left arm, worse in exertion*

Bruise easily, "black and blue" spots*

Tendency to anemia*

"Nose bleeds" frequent*

Noises in head or "ringing ears"*

Breastbone "tightness" in exertion*

Section D Total

E. Liver

Dizziness*

Dry skin*

Burning feet*

Blurred vision*

Itching skin and feet*

Excessive hair loss*

Frequent skin rashes*

Bitter/metallic taste in mouth in mornings*

Bowel movements painful or difficult*

Worrier, feel insecure*

Feel queasy; headache over eyes*

Greasy foods upset*

Stools light-colored*

Skin peels on foot soles*

Pain between shoulder blades*

Use laxatives*

Stools alternate from soft to watery*

History of gallbladder attacks or gallstones*

Sneezing attacks*

Bad dreams or nightmares*

Bad breath (halitosis)*

Milk products cause distress*

Sensitive to hot weather*

Burning or itching anus*

Crave sweets*

Section E Total

F. Digestion

Loss of taste for meat*

Lower bowel gas 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; up to 3-4 hours*

Mucous colitis or "irritable bowel"*

Gas shortly after eating*

Stomach "bloating" after eating*

Section F Total

G-1. Endocrine - Hyperthyroid

Insomnia*

Nervousness*

Can't gain weight*

Intolerance to heat*

Highly emotional*

Flush easily*

Night sweats*

Thin, moist skin*

Inward trembling*

Heart palpitations*

Increased appetite without weight gain*

Pulse fast at rest*

Eyelids and face twitch*

Irritable and restless*

Can't work under pressure*

Section G.1 Total

G-2 Endocrine - Hypothyroid

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*

Headache upon arising, wears off during the day*

Slow pulse, below 65*

Frequency of urination*

Impaired hearing*

Reduced initiative*

Section G.2 Total

G-3. Endocrine - Hyperpituitary

Failing memory*

Low blood pressure*

Increased sex drive*

Headaches, "splitting" or "rendering" type*

Decreased sugar tolerance*

Section G.3 Total

G-4. Endocrine - Hypopituitary

Abnormal thirst*

Bloating of abdomen*

Weight gain around hips or waist*

Sex drive reduced or lacking*

Tendency to ulcers, colitis*

Increased sugar tolerance*

Section G.4 Total

G-5. Endocrine - Hyperadrenal

Dizziness*

Headaches*

Hot flashes*

Increased blood pressure*

Sugar in urine (not diabetic)*

Section G.5 Total

G-6. Endocrine - Hypoadrenal

Weakness, dizziness*

Chronic fatigue*

Low blood pressure*

Nails weak, rigid*

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*

Section G.6 Total

H. B Complex

Apprehension*

Irritability*

Morbid fears*

Never seem to get well*

Forgetfulness*

Indigestion*

Poor appetite*

Craving for sweets*

Muscular soreness*

Depression; feelings of dread*

Noise sensitivity*

Acoustic hallucinations*

Tendency to cry without reason*

Hair is coarse and/or thinning*

Weakness*

Fatigue*

Skin sensitive to touch*

Tendency toward hives*

Nervousness*

Headache*

Insomnia*

Anxiety*

Anorexia*

Inability to concentrate; confusion*

Frequent stuffy nose; sinus infections*

Allergy to some foods*

Loose joints*

Section H Total

I. Female - Male - Youth

Prostate trouble*

Urination difficult or dribbling*

Night urination frequent*

Depression*

Pain on inside of legs or heels*

Feeling of incomplete bowel evacuation*

Lack of energy*

Migrating aches and pains*

Tire too easily*

Avoid activity*

Leg nervousness at night*

Diminished sex drive*

Section I Total

Symptom Survey Total

Nutritional ID Questionnaire

1. If you had a full morning schedule and had to be at your peak until lunch, knowing that you would have no opportunity to snack or reach for a stimulant such as caffeine to keep you going, which of these breakfast choices would give you the highest sustained energy?*

2. What are your thoughts about salt?*

3. If you have ever been on a juice or water fast for any length of time how did you react?*

4. At Thanksgiving dinner, when the turkey plate is being passed around, which would you prefer?*

5. If you had a full afternoon schedule and had to be at your peak until after dinner, knowing that you would have no opportunity to snack or reach for a stimulant such as caffeine to keep you going, which of these lunch choices would give you the highest sustained energy?*

6. You are given the choice of a lighter fish such as tilapia or a heavier fish such as salmon.*

7. If you are out for a celebratory dinner and you are going to eat dessert with no guilt attached, which would you choose?*

8. How do you feel about eating dessert?*

9. If I would consume sweets on their own such as candies, cookies or cakes I would feel...*

10. If you had a full evening schedule and had to be at your peak until bedtime, knowing that you would have no opportunity to snack or reach for a stimulant such as caffeine to keep you going, which of these dinner choices would give you the highest sustained energy?*

11. If you consumed a cup of caffeinated coffee on an empty stomach, how would you feel?*

12. I experience the most significant weight gain when...*

13. If I skip a meal I will feel...*

If your score is between 6 thru 14, you would begin your Base Nutritional Plan as a Protein Type
If your score is between -5 thru 5, you would begin your Base Nutritional Plan as a Mixed Type
If your score is between -14 thru -6, you would begin your Base Nutritional Plan as a Veggie Type

Nutritional ID Score

Gut/Gluten Questionnaire

If your score is 4 or Less, your potential for gluten intolerance is: Not likely
If your score is between 5 thru 8, your potential for gluten intolerance is: Suspected
If your score is 9 or more, your potential for gluten intolerance is: Very likely

Gut/Gluten Questionnaire Score