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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Symptom Survey Form
PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:

Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

INSTRUCTIONS: Mark only the number that applies to you.
  (1) for MILD symptoms (occur once or twice a year)
  (2) for MODERATE symptoms (occur several times a year)
  (3) for SEVERE symptoms (you are aware of it almost constantly)

IMPORTANT: If a question applies to you and is asked more than once, answer it every time it is asked.

GROUP 1
1. Acid foods upset 1 2 3
2. Get chilled, often 1 2 3
3. Lump in throat 1 2 3
4. Dry mouth-eyes-nose 1 2 3
5. Pulse speeds after meals 1 2 3
6. Keyed up-fail to calm 1 2 3
7. Cuts heal slowly 1 2 3
8. Gag easily 1 2 3
9. Unable to relax; startles easily 1 2 3
10. Extremities cold, clammy 1 2 3
11. Strong light irritates 1 2 3
12. Urine amount reduced
 1 2 3
13. Heart pounds after retiring 1 2 3
14. "Nervous" stomach 1 2 3
15. Appetite reduced 1 2 3
16. Cold sweats often 1 2 3
17. Fever easily raised 1 2 3
18. Neuralgia-like pains 1 2 3
19. Staring, blinks little 1 2 3
20. Sour stomach frequent 1 2 3
Group 2
21. Joint stiffness after arising 1 2 3
22. Muscle-leg-toe cramps at night 1 2 3
23. Butterfly stomach, cramps 1 2 3
24. Eyes or nose watery 1 2 3
25. Eyes blink often 1 2 3
26. Eyelids swollen, putty 1 2 3
27. Indigestion soon after meals 1 2 3
28. Always seems hungry; feels "lightheaded" often 1 2 3
29. Digestion rapid 1 2 3
30. Vomiting frequent 1 2 3
31. Hoarseness frequent 1 2 3
32. Breathing irregular
 1 2 3
33. Pulse slow; feels irregular 1 2 3
34. Gagging reflex slow 1 2 3
35. Difficulty swallowing 1 2 3
36. Constipation, diarrhea alternating 1 2 3
37. Slow starter 1 2 3
38. Get "chilled" infrequently 1 2 3
39. Perspire easily 1 2 3
40. Circulation poor; sensitive to cold 1 2 3
41. Subject to colds, asthma, bronchitis 1 2 3
Group 3
42. Eat when nervous 1 2 3
43. Excessive appetite 1 2 3
44. Hungry between meals 1 2 3
45. Irritable before meals 1 2 3
46. Get shaky if hungry 1 2 3
47. Fatigue, eating relieves 1 2 3
48. "Lightheadedness" if meals delayed 1 2 3
49. Heart palpitates if meals missed or delayed 1 2 3
50. Afternoon headaches 1 2 3
51. Overeating sweets upsets 1 2 3
52. Awaken after few hours sleep-hard to get back to sleep 1 2 3
53. Crave candy or coffee in afternoons 1 2 3
54. Moods of depression - "blues" or melancholy 1 2 3
55. Abnormal craving for sweets or snacks 1 2 3
Group 4
56. Hands and feet go to sleep easily; numbness 1 2 3
57. Sign frequently. "Air Hunger" 1 2 3
58. Aware of "breathing heavily" 1 2 3
59. High altitude discomfort 1 2 3
60. Opens windows in closed room 1 2 3
61. Susceptible to colds and fevers 1 2 3
62. Afternoon "Yawner" 1 2 3
63. Get drowsy often 1 2 3
64. Swollen ankles worse at night 1 2 3
65. Muscle cramps, worse during exercise, get charley horses 1 2 3
66. Shortness of breath on exertion 1 2 3
67. Dull pain in chest or radiating into left arm, worse on exertion 1 2 3
68. Bruise easily; "black and blue" spots 1 2 3
69. Tendency to anemia 1 2 3
70. Nose bleeds frequent 1 2 3
71. Noises in head or ringing in ears 1 2 3
72. Tension under the breastbone, or feeling of tightness, worse on exertion 1 2 3
Group 5
73. Dizziness 1 2 3
74. Dry skin 1 2 3
75. Burning feet 1 2 3
76. Blurred vision 1 2 3
77. Itching skin and feet 1 2 3
78. Excessive falling hair 1 2 3
79. Frequent skin rashes 1 2 3
80. Bitter, metallic taste in mouth in mornings 1 2 3
81. Bowel movements painful or difficult 1 2 3
82. Worrier, feels insecure 1 2 3
83. Feeling queasy; headache over eyes 1 2 3
84. Greasy foods upset
1 2 3
85. Stools light-colored 1 2 3
86. Skin peels on foot soles 1 2 3
87. Pain between shoulder blades 1 2 3
88. Use Laxatives 1 2 3
89. Stools alternate from soft to watery 1 2 3
90. History of gallbladder attacks or gallstones 1 2 3
91. Sneezing attacks 1 2 3
92. Dreaming, nightmare type bad dreams 1 2 3
93. Bad breath (halitosis) 1 2 3
94. Milk products cause distress 1 2 3
95. Sensitive to hot weather 1 2 3
96. Burning or itching anus 1 2 3
97. Craves Sweets 1 2 3
Group 6
98. Loss of taste for meat 1 2 3
99. Lower Bowel gas several hours after eating 1 2 3
100. Burning stomach sensations, eating relieves 1 2 3
101. Coated tongue 1 2 3
102. Pass large amounts of foul-smelling gas 1 2 3
103. Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hrs. 1 2 3
104. Mucus colitis or "irritable bowels" 1 2 3
105. Gas shortly after eating 1 2 3
106. Stomach bloating alter eating 1 2 3

Group 7
(A)

107. Insomnia 1 2 3
108. Nervousness 1 2 3
109. Can't gain weight 1 2 3
110. Intolerance to heat 1 2 3
111. Highly emotional 1 2 3
112. Flush easily 1 2 3
113. Night sweats 1 2 3
114. Thin, moist skin 1 2 3
115. Inward trembling 1 2 3
116. Heart palpitates 1 2 3
117. Increased appetite without weight gain 1 2 3
118. Pulse fast at rest 1 2 3
119. Eyelids and face twitch 1 2 3
120. Irritable and restless 1 2 3
121. Can't work under pressure 1 2 3

(B)
122. Increase in weight 1 2 3
123. Decrease in appetite 1 2 3
124. Fatigue easily 1 2 3
125. Ringing in ears 1 2 3
126. Sleepy during day 1 2 3
127. Sensitive to cold 1 2 3
128. Dry or scaly skin 1 2 3
129. Constipation 1 2 3
130. Mental sluggishness 1 2 3
131. Hair coarse, falls out 1 2 3
132. Headaches upon arising wear off during day 1 2 3
133. Slow pulse, below 65 1 2 3
134. Frequency of urination 1 2 3
135. Impaired hearing 1 2 3
136. Reduced initiative 1 2 3

(C)
137. Failing memory 1 2 3
138. Low blood pressure 1 2 3
139. Increased sex drive 1 2 3
140. Headaches, "splitting or rending" type 1 2 3
141. Decreased sugar tolerance 1 2 3

(D)

142. Abnormal thirst 1 2 3
143. Bloating of abdomen 1 2 3
144. Weight gain around hips or waist 1 2 3
145. Sex drive reduced or lacking 1 2 3
146. Tendency to ulcers, colitis 1 2 3
147. Increased sugar tolerance 1 2 3
148. Women: menstrual disorders 1 2 3
149. Young girls: lack of menstrual function 1 2 3

(E)

150. Dizziness 1 2 3
151. Headaches 1 2 3
152. Hot flashes 1 2 3
153. Increased blood pressure 1 2 3
154. Hair growth on face or body (female) 1 2 3
155. Sugar in urine (not diabetes) 1 2 3
156. Masculine tendencies (female) 1 2 3

(F)

157. Weakness, dizziness 1 2 3
158. Chronic fatigue 1 2 3
159. Low blood pressure 1 2 3
160. Nails weak, ridged 1 2 3
161. Tendency to hives 1 2 3
162. Arthritic tendencies 1 2 3
163. Perspiration increase 1 2 3
164. Bowel disorders 1 2 3
165. Poor circulation 1 2 3
166. Swollen ankles 1 2 3
167. Crave salt 1 2 3
168. Brown spots or bronzing of skin 1 2 3
169. Allergies-tendency to asthma 1 2 3
170. Weakness after colds, influenza 1 2 3
171. Exhaustion-muscular and nervous 1 2 3
172. Respiratory disorders 1 2 3


Female Only
173. Very easily fatigued 1 2 3
174. Premenstrual tension 1 2 3
175. Painful menses 1 2 3
176. Depressed feelings before menstruation 1 2 3
177. Menstruation excessive and prolonged 1 2 3
178. Painful breasts 1 2 3
179. Menstruate too frequently 1 2 3
180. Vaginal discharge 1 2 3
181. Hysterectomy/ovaries removed 1 2 3
182. Menopausal hot flashes 1 2 3
183. Menses scanty or missed 1 2 3
184. Acne, worse at menses 1 2 3
185. Depression of long standing 1 2 3
Male Only
186. Prostate trouble 1 2 3
187. Urination difficult or dribbling 1 2 3
188. Night urination frequent 1 2 3
189. Depression 1 2 3
190. Pain on inside of legs or heels 1 2 3
191. Feeling of incomplete bowel evacuation 1 2 3
192. Lack of energy 1 2 3
193. Migrating aches and pains 1 2 3
194. Tire too easily 1 2 3
195. Avoids activity 1 2 3
196. Leg nervousness at night 1 2 3
197. Diminished sex drive 1 2 3

IMPORTANT: Please list below the five main health complaints you have in order of their importance:
1.
2.
3.
4.
5.