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Life Enhancing Wellness System Survey
This will help the doctor focus on your "weak" systems in order to apply the best nutritional and chiropractic therapies.
Symptom Survey
If you have the listed symptom then select the column that best describes how bad or often you experience that symptom if you do not have the listed symptom then click the "NEVER" button as ALL lines must be filled in in each section. At the end of this survey there is a section for just for Women and men can skip this and there is a section just for Men, and women can skip that one.
Have patience and complete this entire form with your best concentration.
This is an extensive form with 16 sections to fill out, it will take you approximately 15-30 minutes to completely fill it out, be a patient, patient. The doctor is very thorough and asks questions other doctors may not that is why you are here. He does things other doctors don't usually do to get you results you have been looking for. All good things take time.
Name
First Name
Last Name
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
Page Total Score (This will automatically fill in when you are done and have submitted your form).
Digestion
*
Never
Sometimes
Frequently
Almost all the time
Indigestion
Acid Reflux
GERD
Nausea
Sulfur taste after burping
Sharp burning abdominal pain right after eating
Sharp burning abdominal pain a while (1hr+) after eating
Belching or burping a lot
Bloating after eating
Frequent flatulence
Lower stomach/abdomen sharp pains
Middle stomach/abdomen pains
Pain on the right or left upper to middle abdomen
Testicular pain right
Testicular pain left
Groin pain right
Groin pain left
Digestion Section Total
Elimination
*
Never
Sometimes
Frequently
Almost all the time
Diarrhea
Constipation (less than 2 BM/day)
Constipation (firm, painful or uncomfortable BM)
Black stools
Yellowish stools
Bright red blood in stools
Dark red blood blood in stools
Frequent flatulence
Hemorrhoids
IBS
Crohn's Disease
Lower back pain during BM
Elimination Section Total
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Group 1
*
Never
Sometimes
Frequently
Almost all the time
Gets cold after eating
Heart races after eating
Acid foods bother you
Feels jittery after eating
Pulse speeds up after eating
Can't calm down easily
Hands and/or feet cold/clammy
Frequent flatulence
Dry mouth, eyes, nose
Gags easily
Can't sleep if eats too late
Lump in throat
Trouble swallowing
Poor appetite
Light bothers you
Skin is sensitive to being touched
Stares, doesn't blink much
Cold sweats a lot
Upset stomach even when not eating
Cuts heal slowly
Group 1 Section Total
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Group 2
*
Never
Sometimes
Frequently
Almost all the time
Poor circulation of gets cold easily
Poor Gag Reflex
Stomach cramps "butterflies"
Joint stiffness after waking in the mornings
Sore muscles
Toes, feet, legs cramp at night
Hands and/or feet cold/clammy
Indigestion soon after eating
Eyes blink a lot
Swollen eyelids, puffy
Light-headed hungry a lot
Frequent hoarse voice
Vomits a lot
Poor appetite
Light bothers you
Slow or irregular pulse
Slow to get started in the mornings
Not easily chilled
Group 2 Section Total
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Group 3
*
Never
Sometimes
Frequently
Almost all the time
Nervous Eater
Excessive appetite
Irritable before meals
Hungry a lot
Fatigued-eating relieves it
Light headed if meals are delayed
Upset feelings if eats too many sweets
Afternoon headaches
Awakes after a few hours of sleep hard to fall back asleep
Craves sweets
Craves candy or offee (caffeine) in the afternoons
Depressed or "down" a lot
Heart palpitations if missed a meal
Group 3 Section Total
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Group 4
*
Never
Sometimes
Frequently
Almost all the time
Hands and feet fall asleep go numb easily
Yawn or sigh a lot "air hunger"
Afternoon Yawner
Opens windows in closed rooms
Gets drowsy easily
Ankles swell worse at night
Catches colds and mild fevers a lot
Muscle cramps worse during exercise/strenuous activity
Tension under breastbone hard to take a deep breath
Dull pain in chest radiates down left arm or up to jaw, worse on exertion
Shortness of breath on exertion
Bruise easily
Frequent nose bleeds
Ringing in ears
Dizziness
Tendency towards anemia
Group 4 Section Total
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Group 5
*
Never
Sometimes
Frequently
Almost all the time
Dry Skin
Burning feet
Itchy feet
Excessive falling hair on brush or sink
Metallic taste in mouth in the mornings
Skin rashes
Difficult or painful bowel movements
Light colored, grey stools
Feelings of dread or gloom
Headaches over eyes
Peeling skin on soles of feet
Pain between shoulder blades
Using laxatives
Greasy foods upset stomach
History of gall bladder issues/stones
Nightmares, violent dreams
Sneezing attacks
Stools alternate from lose to hard
Bad breath
Burning, itching anus
Milk bothers stomach
Sensitive to hot weather
Craves sweets
Group 5 Section Total
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Group 6
*
Never
Sometimes
Frequently
Almost all the time
Loss of taste for red meat
Foul gas after eating
Indigestion 1/2-1 hr after eating or 3-4 hrs
Burning stomach pain, eating relieves it
Coated tongue
Mucus in stools, Colitis, or IBS
Bloating (stomach) after eating
Lower GI bowel gas, discomfort after eating
Group 6 Section Total
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Group 7a
*
Never
Sometimes
Frequently
Almost all the time
Insomnia
Intolerance to heat
Can't gain weight
Flush easily
Nervousness
Nigh sweats
Skin is thin and moist
Pulse races when resting
Increased appetite but can't gain weight
Can't work under pressure
Irritable and restless feelings
Face or eyelids twitch
Group 7a Section Total
Group 7b
*
Never
Sometimes
Frequently
Almost all the time
Noticeable weight gain
Decreased appetite
Easily fatigued
Ringing in ears
Sleepy during the day
Dry or scaly skin
Constipation
Mental slugishness
Headaches upon rising get better as day progresses
Reduce initiative
Slow pulse <65 bpm
Frequent urination
Trouble hearing
Hair is coarse and falls out easily
Group 7b Section Total
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Group 7c
*
Never
Sometimes
Frequently
Almost all the time
Increased sex drive
Splitting headaches
Low Blood Pressure
Decreased sugar tolerance
Failing memory
Group 7c Section Total
Group 7d
*
Never
Sometimes
Frequently
Almost all the time
Decreased/no sex drive
Weight gain around hips and waist
Low Blood Pressure
Tendency toward ulcers and colitis
Abnormal thirst
Menstrual issues (mature women)
No menstruation (young girls that should be menstruating)
Bloating around the abdomen
Increased sugar tolerance (can eat a lot and not feel tired or bloated)
Group 7d Section Total
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Group 7e
*
Never
Sometimes
Frequently
Almost all the time
Sugar in urine
Dizziness
Headaches
Hot Flashes
Increased Blood Pressure
Masculine Tendencies (WOMEN ONLY)
Facial Hair (WOMEN ONLY)
Group 7e Section Total
Group 7f
*
Never
Sometimes
Frequently
Almost all the time
Weakness or dizziness
Chronis Fatigue
Low Blood Pressure
Ridges or weak nails
Tendency to get hives
Perspires a lot
Arthritis
Bowel issues
Poor circulation
Craves salt
Swollen ankles
Brown spots on skin
Respiratory disorders
Allergies, tending towards Asthma
Weakness after recovering from a cold or the Flu
Muscle and nerve exhaustion
Group 7f Section Total
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Group 8
*
Never
Sometimes
Frequently
Almost all the time
Apprehension
Morbid Fears
Never seem to get well
Forgetfulness
Poor appetite
Indigestion
Craves sweets
Muscle soreness
Acoustic hallucinations
Noise sensitivity
Depression
Fatigue
Heahaches
Sensitive skin
Get injured easily
Inability to concentrate
Insomnia
Anxiety
Anorexia
Trouble concentrating, confusion
stuff nose
Lose joints "double jointed"
Allergy to some foods
Group 8 Section Total
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Women Only (skip this if you are a man)
Never
Sometimes
Frequently
Almost all the time
Painful periods
PMS
Depression before menstruation
Easily fatigued
Breast tenderness
Prolonged menstruation
Heavy bleeding
Vaginal discharge
Painful intercourse
Missing periods or scant periods
Acne worse with period
Menopausal hot flashes
Memory issues
Long standing Depression
Hysterectomy, partial or complete
Women Only Section Total
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Men Only (skip this if you are a woman)
Never
Sometimes
Frequently
Almost all the time
Prostate Issues
Prostate removed/radiated
Frequent urination at night
Pain on the inside of legs or heels
Feeling of incomplete bowel evacuation after BM
Migrating aches and pains
Lack of energy
Memory issues
Leg issues at night
Nervousness
Low or no sex drive
Erectile Disfunction (cannot get or maintain an erection)
Migrating aches and pains in major joints
Bilateral shoulder pain
Bilateral hip or knee pain
Easily tired
Poor urine stream or dribble when finished urinating
Men Only Section Total
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