You will fill out a form online where you will answer 200 questions as they pertain to the symptoms you have.
SYSTEMS SURVEY FORM
You will then receive a personalized report similar to this I will review each report personally and customize any recommendations report.
Patient Patient, Sample Report
NOTE: 0 Approx Weight PLEASE
Birth Date Pulse: Recumbent Blood pressure: Recumbent
Doctor Ward Hale, AP
/
Standing
Female
No
Be sure to follow these instructions when filling out your survey Awaken after few hours sleep - hard to get back to sleep 3 Crave candy or coffee in afternoons 3 Moods of depression - "blues" or melancholy Abnormal craving for sweets or snacks
52 53 54 55
1 2 3 GROUP 1 - Sympathetic Dominance 1 1 Acid foods upset Pages 1 & 2 are a summary of 2 1 Get chilled often the answers you provided 3 "Lump" in throat 4 1 Dry mouth-eyes-nose This is a generic sample test 5 1 Pulse speeds after meal which I have created. I have 6 Keyed up - fail to calm included several main complaints 7 Cut heals slowly and quite a few functional findings 8 Gag easily 9 2 Unable to relax; startles easily that relate to several different body systems. Not everyone will 10 2 Extremities cold, clammy have so many indications. This 11 1 Strong light irritates report is provided only for 12 Urine amount reduced purposes of illustration. Your 13 1 Heart pounds after retiring report may or may not be so 14 2 "Nervous" stomach involved. I only ask that everyone 15 Appetite reduced answer the questions as honestly 16 Cold sweats often as possibly and follow the 17 Fever easily raised instructions. 18 Neuralgia-like pains 19 3 Staring, blinks little 20 1 Sour stomach often
GROUP 3 - Sugar Handling 42 3 Eat when nervous 43 2 Excessive appetite 44 Hungry between meals 45 3 Irritable before meals 46 3 Get "shaky" if hungry 47 3 Fatigue, eating relieves 48 3 "Lightheaded" if meals delayed 49 1 Heart palpitates if meals missed or delayed 50 3 Afternoon headaches 51 Overeating sweets upsets
Vegetarian:
¨ Yes ¨
Male
1 2 3
MILD symptoms (occurred once or twice last 6 months). MODERATE symptoms (occurred once or twice last month). SEVERE symptoms (chronic, occurred once or twice last week). Leave circles BLANK if they don't apply to you!
GROUP 2 - Parasympathetic Dominance 21 2 Joint stiffness on arising 22 2 Muscle-leg-toe cramps at night 23 2 "Butterfly" stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen, puffy 27 2 Indigestion soon after meals 28 3 Always seems hungry; feels "lightheaded" often 29 Digestion rapid 30 Vomiting frequent 31 3 Hoarseness frequent 32 Breathing irregular 33 2 Pulse slow; feels "irregular" 34 Gagging reflex slow 35 Difficulty swallowing 36 Constipation, diarrhea alternating 37 "Slow starter" 38 1 Get "chilled" infrequently 39 Perspire easily 40 2 Circulation poor, sensitive to cold 41 2 Subject to colds, asthma, bronchitis
þ þ Ragland's Test is Positive ¨
Sex:
THIS SURVEY IS HIPPA COMPLAINT Standing Your medical privacy will / be protected!
INSTRUCTIONS: Fill in only the circles which apply to you.
Date 08/23/2011
GROUP 4 - Cardio-Vascular 56 2 Hands and feet go to sleep easily, numbness 57 2 Sigh frequently, "air hunger" 58 2 Aware of "breathing heavily" 59 High altitude discomfort 60 Opens windows in closed rooms 61 2 Susceptible to colds and fevers 62 Afternoon "yawner" 63 3 Get "drowsy" often 64 Swollen ankles, worse at night 65 Muscle cramps, worse during exercise; get "charley horses" 66 Shortness of breath on exertion 67 Dull pain in chest or radiating into left arm, worse on exertion 68 3 Bruise easily, "black and blue" spots 69 Tendency to anemia 70 1 "Nose bleeds" frequent 71 3 Noises in head, or "ringing in ears" 72 2 Tension under the breastbone, or feeling of "tightness", worse on exertion 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97
98 99 100 101 102 103 104 105 106
2 2
2
2
2 2 2
GROUP 5 - Biliary / Liver 3 Dizziness 3 Dry skin Burning feet 3 Blurred vision Itching skin and feet Excessive falling hair Frequent skin rashes Bitter, metallic taste in mouth in mornings Bowel movements painful or difficult 3 Worrier, feels insecure 3 Feeling queasy; headache over eyes Greasy foods upset Stools light colored Skin peels on foot soles 3 Pain between shoulder blades Use laxatives Stools alternate from soft to watery History of gallbladder attacks or gallstones Sneezing attacks 3 Dreaming, nightmare type bad dreams Bad breath (halitosis) Milk products cause distress Sensitive to hot weather Burning or itching anus Crave sweets
2 3 3 3 3 3 3
GROUP 6 - Digestive 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; may be up to 3-4 hrs. Mucous colitis or "irritable bowel" Gas shortly after eating Stomach "bloating" after eating