Health Survey

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Health Survey

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Option 1

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Name and age

Acid food upset?

Mild

Moderate

Severe

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Get Chilled often

Mild

Moderate

Severe

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"Lump" In Throat

Mild

Moderate

Severe

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Dry Mouth, Eyes, Nose

mild

Moderate

Severe

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Pulse speeds after meal

Mild

Moderate

Severe

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Keyed Up, Fail to calm

Mild

Moderate

Severe

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Gag Occasionally

Mild

Moderate

Severe

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Unable to relax, startle easily

Mild

Moderate

Severe

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Extremities, cold, clammy

mild

moderate

Severe

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Strong Light Irritates

Mild

Moderate

Severe

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Occasionally weak urine flow

Mild

Moderate

Severe

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Heart pounds after retiring

Mild

Moderate

Severe

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"Nervous" Stomach

Mild

Moderate

Severe

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Appetite reduced occasionally

Mild

Moderate

Severe

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Cold sweats often

Mild

Moderate

Severe

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Get heated easily

Mild

Moderate

Severe

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Nerve Discomfort

Mild

Moderate

Severe

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Staring, blink little

Mild

Moderate

Severe

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Sour Stomach Frequent

Mild

Moderate

Severe

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