Sage
Sign in to Google to save your progress. Learn more
Personal Information
Name ( Last, First ) *
Age *
Gender *
Weight(lbs) *
Height(f' ") *
Chief Complaints top 1 ~ 3 *
Please check your symptoms.
  *
Often
Sometimes
No
1. I have a bitter taste in my mouth and I have a poor appetite.
2. I have a hoarse throat often.
3. I easily get tonsillitis.
4. I have phlegm.
5. I get cramps in my leg, experience muscle pain and/or spasms often.
6. I grind my teeth in my sleep.
7. I talk and/or walk in my sleep.
8. I sigh and get tensed often.
9. I have skin fungus from athlete’s foot or eczema on my foot.
10. I have a difficulty breathing and my face flushes while walking or doing nothing.
11. I have a pain in my heart.
12. I get thirsty often.
13. I suffer from a puffy and/or sweaty face.
14. I have pimples on my face and/or body.
15. I have high blood pressure.
16. I have low blood pressure.
17. I have pain around my shoulder blades.
18. I have sciatic nerve pain.
19. I speak with a lisp and/or it is hard to speak clearly.
20. I have a stammering problem.
21. I suffer from gastroptosis.
22. I have a burning feeling from a stomach ulcer or excess acid.
23. I burp a lot.
24. I suffer from bad breath.
25. I have a poor sense of taste.
26. I feel lazy and constantly want to lay down.
27. I get nosebleeds.
28. I sneeze and/or have a runny nose.
29. I have rhinitis or sinusitis.
30. I have a dry cough.
31. I suffer from nephrolithiasis, bladder infection.
32. I have pain in the center of my chest(between the nipples), if I press down with my finger.
33. I feel swelling / numbness in my hands and/or feet.
34. I continuously have either a fever or chills.
35. I have swollen lymph nodes.
36. I have an irregular pulse and/or chest pain(stricture of the heart).
37. I have frozen shoulders and/or arm discomfort( heavy and stiff feeling).
38. I have chest discomfort/ congestion.
39. It is easy for me to become fatigued and I sigh often.
40. I have anxiety and/or mysophobia (OCD).
41. I tend to get suddenly worried or concerned, for no reason.
42. I suffer from Insomnia and/or am a light sleeper.
43. I lose sex drive and/or sexual capacity.
44. I have bloody stools and/or urine.
45. I have hair loss.
46. I cannot stop hiccupping once I start.
Continue..
  *
Often
Sometimes
No
47. I have a headache.
 
  *
Often
Sometimes
No
48. I have eye problems.
 
  *
Often
Sometimes
No
49. I have problems with Fingernails/ Toenails.
 
  *
Often
Sometimes
No
50. I have goose bumps often.
 
  *
Often
Sometimes
No
51. I have or have had a ruptured intestine.
 
  *
Often
Sometimes
No
52. I have joint pain in my thighbone.
 
  *
Often
Sometimes
No
53. I have hepatitis or used to have.
 
  *
Often
Sometimes
No
54. I have gallstone disease.
 
  *
Often
Sometimes
No
55. I have a menstruation problem.
 
  *
Often
Sometimes
No
56. For women : I sometimes discharge blood.
 
  *
Often
Sometimes
No
57. I have lip issues.
 
  *
Often
Sometimes
No
58. I have joint problems.
 
  *
Often
Sometimes
No
59. I have skin problems.
 
  *
Often
Sometimes
No
60. I have appetite problems.
 
  *
Often
Sometimes
No
61. I suffer from piles and/or anal fistula.
 
  *
Often
Sometimes
No
62. I suffer from asthma.
 
  *
Often
Sometimes
No
63. I have bowel movement issues.
 
  *
Often
Sometimes
No
64. I have issues with my ears.
 
  *
Often
Sometimes
No
65. My urine amount is too little and/or I urinate too often.
 
  *
Often
Sometimes
No
66. I have knee pain.
 
  *
Often
Sometimes
No
67. I have breast pain.
 
  *
Often
Sometimes
No
68. I have problems with my palms.
 
  *
Often
Sometimes
No
69. I feel depressed.
 
  *
Often
Sometimes
No
70. I get shy easily.
 
  *
Often
Sometimes
No
71. I feel sad more than normal.
 
  *
Often
Sometimes
No
72. I am jealous of others and/or others' belongings.
 
  *
Often
Sometimes
No
73. I feel pain during intercourse.
 
  *
Often
Sometimes
No
74. I have feet issues.
 
  *
Often
Sometimes
No
75. I am sensitive to cold.
 
  *
Often
Sometimes
No
76. I have varicose veins.
 
  *
Yes
No
77. I have had surgery.
 
  *
Yes
No
No idea
78. Do you think you are obese?
 
Futher Questions
Do you have any additional comments?
Have you ever had any medical conditions as diagnosed by a Medical Professional?
Do you currently take medication/s and if so, for how long have you taken it/them?
Have you had an surgeries not previously listed?
Contact Information
E-mail Address *
Phone Number *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms