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Systems 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
Get chilled often
"Lump" in throat
Dry mouth, eyes, nose
Pulse speeds after meal
Keyed up, fail to calm
Gag occasionally
Unable to relax, startle easily
Extremities cold, clammy
Strong light irritates
Occasionally weak urine flow
Heart pounds after retiring
"Nervous" stomach
Appetite reduced occasionally
Cold sweats often
Get heated easily
Nerve discomfort
Staring, blink little
Sour stomach frequent
Section:
15
Please answer each symptom to continue
Related Information
*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.