SYMPTOM SURVEY FOR INDICATING IMBALANCES TO SUPPORT FUNCTIONAL TESTING
Please indicate on a scale of 1- 10 your perception of each of the following symptoms (0 being fabulous, 10 being awful)
numbing from treats
___ “love” certain foods, behaviors,
Digestion Imbalances
drugs
___ sensitive to emotional, physical
___ diarrhea and/or constipation
pain
___ gas and/or bloating
___ cry easily
___ heartburn or belching
___ use of Vicodin, heroin
___ stomach pains
___ heaviness, food seems to sit
___ bad taste in mouth
___ no appetite, eat erratically
Neurotransmitter Imbalances
___ strong emotions or thoughts of
food aggravates stomach
Type 1
___ hunger 1-2 hours after eating
___ after 3pm cravings
___ nausea with eating
___ negativity, depression
___ pain or difficulty swallowing
___worry, anxiety
___ excessive stool odor
___low self-esteem
___ undigested food in stool
___obsessive thoughts
___<1 or >3 bowel movements/day
___ hyperactivity
Hormonal Imbalances
___ mucus or blood in stool
___ controlling
___ rectal pain or itching
___ perfectionism
___ no urge or constant/intense
Basic
___ winter blues
urge to have a bowel movement
___ hot flashes, night sweats
___ irritability or rage
___ ear infections
___ weight gain, especially waist
___ dislike hot weather
___ mood swings, PMS
___ irritability
___ panic attacks, phobias
___ irritability, aggression
___ mental fogginess
___ fibromyalgia, other pains
___ depression or anxiety
___ sleep disturbance
___ suicidal thoughts
___ fatigue or apathy
___ oily skin, acne
___ hard to fall asleep
___ hyperactivity or restlessness
___ depression, apathy
___ insomnia, disturbed sleep
___ watery/itchy/swollen eyes
___ infertility
___ use of Ecstasy, Prozac, Zoloft,
___ dark circles under eyes
___ decreased libido
Paxil, Effexor, Celexa
___ binge eating or cravings
Women:
___ water retention
___ heart palpitations
___ over or under weight
Type 2
___ heavy menses
___ pain or stiffness in joints
___ craving for stimulation
___ fibrocystic breasts
___ weak or aching muscles
(sugar/chocolate/caffeine/ cocaine)
___ mood swings (PMS)
___chronic cough or clearing throat
___ apathy, depression
___ cystic ovaries, uterine fibroids
___ sore throat
___ lack of drive
___ urinary incontinence
___ canker sores
___ lack of energy
___ increased facial/body hair
___ stuffy nose or sinus problems
___ easily bored
___ vaginal dryness
___ hayfever or sneezing
___ lack of focus, concentration
Men:
___ excessive mucus
___ ADD
___ erectile dysfunction
___ headaches or dizziness
___ use of aspartame, cocaine, diet
___ prostate/urinary problems
___ insomnia
pills, Wellbutrin, Ritalin, Adderall
___ decreased stamina
___ acne
___ decreased muscle mass
___ rashes or itching anywhere
Type 3
___ hair loss
___ crave carbs, alcohol, drugs for
Adrenal
___ flushing or excessive sweating
relaxation
___ sleep disturbances
___ asthma, bronchitis
___ stressed, burned out
___ infertility
___ shortness of breath
___ hard to relax, loosen up
___ elevated triglycerides
___ poor memory
___ tense muscles
___ depression, anxiety
___ poor concentration
___ feel easily overwhelmed
___morning or afternoon fatigue
___ irregular or rapid heartbeat
___ use of Valium, Ativan,
___ allergies
___ frequent illnesses
Neurontin
___ frequent infections
___ urgent urination
___ recurrent/chronic illness
Type 4
___ blood sugar imbalance
___ crave comfort, reward, or
___ dizziness
Balance Naturopathic Healthcare
11340 W. Olympic Blvd. Suite 301, Los Angeles, CA 90064
SYMPTOM SURVEY FOR INDICATING IMBALANCES TO SUPPORT FUNCTIONAL TESTING
Please indicate on a scale of 1- 10 your perception of each of the following symptoms (0 being fabulous, 10 being awful)
___ autoimmune illnesses
Thyroid
___ dry or thin skin
___ thinning or brittle hair or nails
___ fatigue
___ heart palpitations
___ constipation
___ cold hands/feet
___ overall sense of being cold
___ mental fogginess
___ weight gain
___ menstrual irregularities
___ infertility
___ elevated cholesterol
Balance Naturopathic Healthcare
11340 W. Olympic Blvd. Suite 301, Los Angeles, CA 90064