Symptom Survey; Part 1 (Curious Version)


Introduction and Instructions for Symptom Survey:    Instructions
If you have already completed Part 1:    Go to             Part 2
Please press "Reset" before you begin.

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Age: (Required) Gender:  (Required) Male Female
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Health Goals and Concerns

What would you like this survey to accomplish for you? (Required)

What are your personal health concerns? (Required)

Your name and your responses will be strictly confidential.
Choose the best response for each question and complete all sections.
When writing in boxes with a "?" please delete it first.

Pressing clear before you begin resets all answers to:
"None," "Never" and "No."
You need only respond when your answers are one of the other choices.
"Never" is once a year or less.
"Rarely" is once a month or less.
"Often" is more than once a month.
"Usually" is once a week or more.
"Always" is several times a week or more.

Section 1.   Ears

     1. Earaches
Never Rarely Often Usually Always

     2. Ear infections
Never Rarely Often Usually Always

     3. Plugged ears
Never Rarely Often Usually Always

     4. Popping ears
Never Rarely Often Usually Always

     5. Pounding sounds in ears
Never Rarely Often Usually Always

     6. Ringing sounds in ears
Never Rarely Often Usually Always

     7. Coarse hair growing in or on ears
No Yes

     8. Excessive wax in ears
No Yes

     9. Hearing problems, please list details below:
No Yes

Section 2. Eyes

     1. Bloodshot eyes
Never Rarely Often Usually Always

     2. Bright light bothers eyes
Never Rarely Often Usually Always

     3. Burning feeling in eyes
Never Rarely Often Usually Always

     4. Crow's feet at corners of eyes
None Mild Moderate Severe

     5. Dry eyes
Never Rarely Often Usually Always

     6. Dry crusts in corners of eyes
Never Rarely Often Usually Always

     7. Itching eyes
Never Rarely Often Usually Always

     8. Mucus in corners of eyes
Never Rarely Often Usually Always

     9. Night blindness
None Mild Moderate Severe

     10. Bags under eyes
No Yes

     11. Cataracts
No Yes

     12. Dark circles under eyes
No Yes

     13. Farsighted
No Yes

     14. Losing focusing ability
No Yes

     15. Styes, Get
No Yes

     16. Slow accommodation to dark
No Yes

     17. Whites of eyes have yellowish tint
No Yes

Section 3. Nose

     1. Can't breathe through nose
Never Rarely Often Usually Always

     2. Have to blow nose often (Thick mucus)
Never Rarely Often Usually Always

     3. Nose itches inside
Never Rarely Often Usually Always

     4. Nosebleeds
Never Rarely Often Usually Always

     5. Nose runs often (Thin mucus)
Never Rarely Often Usually Always

     6. Sinus drip, back of throat
Never Rarely Often Usually Always

     7. Sinus pressure
Never Rarely Often Usually Always

     8. Adenoids removed
No Yes

Section 4. Throat

     1. "Frog" (lump) in throat
Never Rarely Often Usually Always

     2. Constant throat clearing
Never Rarely Often Usually Always

     3. Cough
Never Rarely Often Usually Always

     4. Difficulty swallowing
Never Rarely Often Usually Always

     5. Laryngitis
Never Rarely Often Usually Always

     6. Sore throats
Never Rarely Often Usually Always

     7. Tonsillitis
Never Rarely Often Usually Always

     8. Hiccups often
No Yes

     9. Tonsils removed
No Yes

Section 5. Mouth

     1. Bad breath
Never Rarely Often Usually Always

     2. Bad taste in mouth
Never Rarely Often Usually Always

     3. "Birdcage" mouth (dry and pasty or gummy)
Never Rarely Often Usually Always

     4. Bleeding gums
Never Rarely Often Usually Always

     5. Canker sores
Never Rarely Often Usually Always

     6. Cavities or infected teeth (Recurring)
Never Rarely Often Usually Always

     7. Coated tongue
Never Rarely Often Usually Always

     8. Cold sores
Never Rarely Often Usually Always

     9. Cracked or bleeding lips
Never Rarely Often Usually Always

     10. Dry, chapped lips
Never Rarely Often Usually Always

     11. Dry mouth or excessive thirst
Never Rarely Often Usually Always

     12. Fever blisters
Never Rarely Often Usually Always

     13. Sores at corners of lips
Never Rarely Often Usually Always

     14. Sore tongue
Never Rarely Often Usually Always

     15. Gingivitis (Gum disease)
No Yes

     16. Loss of sense of taste
No Yes

     17. Periodontal disease
No Yes

     18. Acne like eruptions around mouth only
No Yes

     19. Gold fillings
No Yes

     20. Number of gold fillings (approximate)

     21. Silver fillings
No Yes

     22. Number of silver fillings (approximate)

     23. Tooth brush has blood on it after brushing teeth
Never Rarely Often Usually Always

     24. Use fluoridated toothpaste
No Yes

Section 6. Digestive System

     1. Always hungry, never satisfied
Never Rarely Often Usually Always

     2. Alternate between diarrhea and constipation
Never Rarely Often Usually Always

     3. Belching
Never Rarely Often Usually Always

     4. Burning or acid stomach relieved by eating
Never Rarely Often Usually Always

     5. Candida (Yeast infection)
Never Rarely Often Usually Always

     6. Constipation
Never Rarely Often Usually Always

     7. Diarrhea
Never Rarely Often Usually Always

     8. Eat at bedtime
Never Rarely Often Usually Always

     9. Food poisoning, Get
Never Rarely Often Usually Always

     10. Heartburn, Have
Never Rarely Often Usually Always

     11. Indigestion beginning one half to one hour after eating
Never Rarely Often Usually Always

     12. Indigestion beginning three to four hours after eating
Never Rarely Often Usually Always

     13. Indigestion or upset stomach
Never Rarely Often Usually Always

     14. Intestinal gas (Foul smelling)
Never Rarely Often Usually Always

     15. Reactions to certain foods
Never Rarely Often Usually Always

     16. Which foods cause reactions? List below:

     17. Repeating of food tastes
Never Rarely Often Usually Always

     18. Sour stomach
Never Rarely Often Usually Always

     19. Spicy or acid foods cause upset stomach
Never Rarely Often Usually Always

     20. Stomach aches
Never Rarely Often Usually Always

     21. Gas soon after eating
Never Rarely Often Usually Always

     22. Undigested foods appear in bowel movements
Never Rarely Often Usually Always

     23. Use of laxatives necessary
Never Rarely Often Usually Always

     24. Vomiting
Never Rarely Often Usually Always

     25. Appendix removed
No Yes

     26. Ulcers
No Yes

Congratulations! This is the end of Part 1 of your Symptom Survey.
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Disclaimer. This form is not used for diagnosis.
The responses you give are used to correlate possible
nutritional deficiencies as suggested by your symptoms in
the Symptom Survey with possible contributing factors
found in the Lifestyle Analysis as suggested by your answers
in the Lifestyle Analysis and as correlated with research.
Probable causes will be reported to you along with
strategies or substitutions and/or what
'I or others have or would have done in similar situations'
This document and the responses to it are for educational
purposes only and the choice and responsibility of what you
do remains yours and yours alone.
This is not medical advice and is no substitute for the
services of a medical doctor.
I accept this disclaimer and the personal responsibility it represents.Yes, I accept  (Required)
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