HEALTH & WELLNESS EVALUATION (Restricted to Professional Use) First Name *Last Name *Dropdown *FemaleMaleOtherSingle Line Text *Email *Phone *Date / Time *INSTRUCTIONSSelect the number that applies to you. If a symptom does not apply, leave it blank. Some questions might get repeated in different section please answer them accordingly in each section, Each section represents a system or function. Select either: (1) for MILD symptoms (occurs rarely), (2) for MODERATE symptoms (occur several times a month). (3) for SEVER symptoms (occurs almost constantly). GROUP11-Acid Food Upset my stomach1-Acid food upset01232- Get Chilled, Often2-Get chilled, often0123 Lump in Throat3- “Lump” in throat01234- Dry Mouth-Yes-Nose 4-Dry mouth-eyes-nose0123 5- Pulse speed after meal5-Pulse speeds after meal01236-Keyed up-fail to calm6-Keyed up – fail to calm0123 7-Gag Occasionally7-Gag occasionally01238-Unable to relax, startles easily.8-Unable to relax, startles easily0123 9-Extremities, cold, clammy9-Extremities cold, clammy0123 10-Strong Light irritates10-Strong light irritates0123 11- Occasionally weak Urine flow 11- Occasionally weak Urine flow012312-Heart pounds after retiring12-Heart pounds after retiring0123 13-Nervous Stomach13-“Nervous” stomach012314-Appetite reduced occasionally14-Appetite reduced Occasionally012315-Cold Sweats often15-Cold sweats often012316- Get heated Easily 16- Get heated Easily 012317-Nerve discomfort17-Nerve discomfort012318-Staring, blinks little18-Staring, blinks little012319-Sour Stomach frequent 19-Sour stomach frequent0123GROUP220- joint Stiffness after arising 20-Joint stiffness after arising0123 21-Muscle-leg-toe crams at night21-Muscle-leg-toe cramps at night012322-"Butterfly' stomach cramps22-“Butterfly” stomach, cramps012323-Eyes or nose watery23-Eyes or nose watery012324-Eyes blink often24-Eyes blink often012325-Eyelids swollen, puffy25-Eyelids swollen, puffy012326-Indigestion soon after meals26-Indigestion soon after meals012327-Always seem hungry: feels "lightheaded" often27-always seem hungry; feels “lightheaded “often012328-Digestion rapid28-Digestion rapid012329-Vomiting Occasionally29-Vomiting Occasionally0123 30-Hoarseness frequent30-Hoarseness frequent012331-Uneven breathing31-Uneven breathing012332-Pulse slow32-Pulse slow0123 33-Gagging reflex slow 33-Gagging reflex slow012334-Difficulty swallowing34-Difficulty swallowing12335-Temporary Constipation, or diarrhea 35-Temporary Constipation, or diarrhea 012336-“Slow starter”36-“Slow starter”012337- Get "Chilled" 37-Get “chilled” 012338- perspire easily 38-Perspire easily012339-sensitive to cold39-sensitive to cold012340-Upper respiratory challenges40-Upper respiratory challenges0123GROUP341-Eat when nervous41-Eat when nervous012342-Excessive appetite42-Excessive appetite012343-Hungry between meals43-Hungry between meals012344-Irritable before meals44-Irritable before meals012345- Get "shaky" if hungry45-Get “shaky” if hungry012346-Fatigue, and eating relieves it46-Fatigue, and eating relieves it012347- "Lightheaded" if meals delayed47-“Lightheaded” if meals delayed012348-Heart palpitates if meals missed or delayed48-Heart palpitated if meals missed or delayed012349-Fatigue in Afternoon 49-Fatigue in Afternoon 012350-Overeating sweets upsets50-Overeating sweets upsets012351-waken after few hours sleeps - hard to get back to sleep51-Awake after few hours’ sleep – hard to get back to sleep012352-Crave candy or coffee in afternoons52-Crave candy or coffee in afternoons012353-Moods of depression - "blues" or melancholy53-Moods of depression – “blues” or melancholy012354-Abnormal craving for sweets or snacks54-Abnormal craving for sweets or snacks123GROUP455-Hands and feet go to sleep easily, numbness55-Hand & feet go to sleep easily, numbness012356-Sigh frequently, "air hunger"56-Sigh frequently, “air hunger”012357-Aware of "breathing heavily"57-Aware of “breathing heavily”012358-High altitude discomfort58-High altitude discomfort012359-Opens windows in closed room59-Opens windows in closed room012360-Immune system challenges 60-Immune system challenges 012361-Afternoon "yawner"61-Afternoon “yawner”012362-Get "drowsy" often62-Get “drowsy” often012363-Swollen ankles worse at night63-Swollen ankles worse at night012364-Muscle cramps, worse during exercise; get "Charley horses"64-Muscle cramps, worse during exercise; get “charley horses”012365-difficulty catching breath especially during exercise65-difficulty catching breath especially during exercise012366-Tightness or pressure in chest, worse on exertion66-Tightness or pressure in chest, worse on exertion012367-Bruise easily, after impact67-Bruise easily, after impact 012368-Tendency to anemia68-Tendency to anemia012369-“Noises in head, or “ringing in ears”69-“Noises in head, or “ringing in ears”012370-Fatigue upon excretion70-Fatigue upon excretion0123GROUP571-Dizziness71-Dizziness012372-Dry skin72-Dry skin012373-Burning feet73-Burning feet012374-Blurred Vision74-Blurred Vision0123 75-Itching skin & feet75-Itching skin & feet0123 76-Hair Loss76-Hair Loss012377-Occasional skin rashes77-Occasional skin rashes0123 78-Bitter, metallic taste in mouth in mornings78-Bitter, metallic taste in mouth in mornings012379-Occasional constipation79-Occasional constipation012380-Worrier, feels insecure80-Worrier, feels insecure012381- Nausea occasionally after eating81- Nausea occasionally after eating0123 82-Greasy foods upset82-Greasy foods upset012383-Stools light-colored83-Stools light-colored12384-Skin peel on foot soles84-Skin peel on foot soles12387-Discomfort between shoulder blades85-Discomfort between shoulder blades12386-occasional Use of laxatives86-Occasional Use of laxatives12387-Stools alternate from soft to watery87-Stools alternate from soft to watery12388-Sneezing attacks88-Sneezing attacks12389-Dreaming, nightmare type bad dreams89-Dreaming, nightmare type bad dreams12390-Bad breath (halitosis)90-Bad breath (halitosis)12391-Milk products cause distress91-Milk products cause distress123 92-Sensitive to hot weather92-Sensitive to hot weather12393-Burning or itching anus93-Burning or itching anus12394-Crave sweets94-Crave sweets123GROUP6 95-Loss of taste for meat95-Loss of taste for meat12396-Lower bowel gas several hours after eating96-Lower bowel gas several hours after eating12397-Burning stomach sensation, eating relieves97-Burning stomach sensation, eating relieves12398-Coated tongue98-Coated tongue12399-Pass large amounts of soul-smelling gas99-Pass large amounts of soul-smelling gas123 100-Indigestion ½ -1 hour after eating may be up 3-4 hours after 100-Indigestion ½ -1 hour after eating may be up 3-4 hours after123101- Watery or loose stool101- Watery or loose stool123102-Gas shortly after eating102-Gas shortly after eating123103-Stomach “bloating” 103-Stomach “bloating” 123GROUP77(A) 104-Difficulty sleeping 104-Difficulty sleeping123 105-On edge105-On edge123106-Can’t gain weight106-Can’t gain weight123 107-Intolerance to heat107-Intolerance to heat123 108-Highly emotional108-Highly emotional123109-Flush easily109-Flush easily123110-Night sweats110-Night sweats123 111-Thin, moist skin111-Thin, moist skin123112-Inward trembling112-Inward trembling123113-Heart race113-Heart race123114-Increased appetite without weight gain114-Increased appetite without weight gain123115-Pulse fast at rest115-Pulse fast at rest123116-Eyelids & face twitch116-Eyelids & face twitch123117-Irritable & restless117-Irritable & restless123118-Can’t work under pressure118-Can’t work under pressure1237(B) 119-Increase in weight119-Increase in weight123120-Decrease in appetite120-Decrease in appetite123 121-Fatigue easily121-Fatigue easily123 122-Ringing in ears122-Ringing in ears123123-Sleepy during day123-Sleepy during day123124-Sensitive to cold124-Sensitive to cold123125-Dry or scaly skin125-Dry or scaly skin123126-Temporary Constipation126-Temporary Constipation123127-Mental sluggishness)127-Mental sluggishness123128-Hair course, falls out128-Hair course, falls out123132-Tension Headaches upon arising wear off during day129-Tension Headaches upon arising wear off during day123130-Slow pulse, below 65130-Slow pulse, below 65123131- changing urinary function131- changing urinary function123132-Sound appears diminished132-Sound appears diminished123 133-Reduced initiative133-Reduced initiative1237(C) 134-Falling memory with age134-Falling memory with age123135-Increased Sex Drive135-Increased Sex Drive123136- Episodes of tension in head136- Episodes of tension in head123137-Decreased Sugar tolerance137-Decreased Sugar tolerance1237(D)138-Abnormal thirst138-Abnormal thirst123139-Bloating of abdomen139-Bloating of abdomen123 140-Weight gain around hips or waist140-Weight gain around hips or waist123141-Sex drive reduced or lacking141-Sex drive reduced or lacking123142-Tendency to stomach issues142-Tendency to stomach issues123143-Immune System challenges 143-Immune System challenges 123144-Women: Menstrual disorders144-Women: Menstrual disorders1237(E)145-Dizziness145-Dizziness123146-Headaches146-Headaches123152-Hot flashes147-Hot flashes123148-Hair growth on face or body (female)148-Hair growth on face or body (female)123149-Sugar in urine (not diabetes)149-Sugar in urine (not diabetes)123150-Masculine tendencies (female)150-Masculine tendencies (female)1237(F)151-Weakness, dizziness151-Weakness, dizziness123152-Tired throughout day152-Tired throughout day123153-Nails, weak, ridged)153-Nails, weak, ridged123154-Sensitive skin154-Sensitive skin123155-Stiff joints155-Stiff joints123 156-Perspiration increase156-Perspiration increase123157-Bowel discomfort157-Bowel discomfort123158-Poor circulation)158-Poor circulation123159-Swollen ankles159-Swollen ankles123160-Crave salt160-Crave salt123161-area of skin darkening161-area of skin darkening123162-Upper respiratory sensitivity162-Upper respiratory sensitivity123163-tiredness163-tiredness123164- Breathing challenges164- Breathing challenges 123GROUP8 165-Muscle weakness)165-Muscle weakness123166-Lack of stamina166-Lack of stamina123167-Drowsiness after eating167-Drowsiness after eating123168-muscle soreness168-muscle soreness123169-Heart races169-Heart races123 170-Hyper-irritable170-Hyper-irritable123171-Feeling of a band around your head171-Feeling of a band around your head123 172-Melancholia (feeling of sadness)172-Melancholia (feeling of sadness)123173-Swelling of ankles173-Swelling of ankles123174-Change in urinary function174-Change in urinary function123 175-Tendency to consume sweets or carbohydrates175-Tendency to consume sweets or carbohydrates123176-Muscle spasms176-Muscle spasms123177-Blurred vision177-Blurred vision123178-Loss of muscular action178-Loss of muscular action123179-Numbness179-Numbness123180-Night sweats180-Night sweats123181-Rapid digestion181-Rapid digestion123182-Sensitivity to noise182-Sensitivity to noise123183-Redness of palms of hands & bottom of feet183-Redness of palms of hands & bottom of feet123184-Visible veins on chest and abdomen184-Visible veins on chest and abdomen123 185-Hemorrhoids185-Hemorrhoids123186-Apprehension (feeling that something bad is going to happen)186-Apprehension (feeling that something bad is going to happen)123 187-Nervousness causing loss of appetite187-Nervousness causing loss of appetite123188-Nervousness with indigestion188-Nervousness with indigestion123189-Gastritis189-Gastritis123190-Forgetfulness190-Forgetfulness123 191-Thinning hair191-Thinning hair123FOR MALE ONLY202-Less involved in exercise/social activities202-Less involved in exercise/social activities123203- Difficult to postpone urination203- Difficult to postpone urination123204-Weak urinary stream204-Weak urinary stream123205-Feeling Blues or melancholy205-Feeling Blues or melancholy123206-Feeling of incomplete bowel evacuation206-Feeling of incomplete bowel evacuation123207-Lack of energy207-Lack of energy123208-Muscles in arms and legs seem softer/smaller208-Muscles in arms and legs seem softer/smaller123209-Tire too easily209-Tire too easily123210-Avoids activity210-Avoids activity123 211-Leg nervousness at night211-Leg nervousness at night123212-Diminished sex drive212-Diminished sex drive123FOR FEMALE ONLY192-very easily fatigues192-very easily fatigues123193-Premenstrual tension193-Premenstrual tension123194-Menses painful than usual194-Menses painful than usual123 195-Depressed feelings before menstruation195-Depressed feelings before menstruation123196-Painful breasts during menses196-Painful breasts during menses123 197-Menstruate too frequently197-Menstruate too frequently123198-Hysterectomy/ovaries removed198-Hysterectomy/ovaries removed123199-Menopausal hot flashes199-Menopausal hot flashes123200-Menses scanty or missed200-Menses scanty or missed123201-Acne, worse at menses201-Acne, worse at menses123IMPORTANTTO THE PATIENT: Please list below the five main physical complaints you have in order of their importance. #1#2#3#4#5NameSubmit Your evaluation
