Standard Process
Systems Survey Form
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Name: *
Age: *
Group 1: *
1: MILD-occurs rarely
2: MODERATE-occurs several times a month
3: SEVERE-occurs almost constantly
Does not occur
1. Acid foods upset
2. Get chilled often
3. "Lump" in throat
4. Dry mouth, eyes, nose
5. Pulse speeds after meal
6. Keyed up, fail to calm
7. Gag occasionally
8. Unable to relax, startle easily
9. Extremities cold, clammy
10. Strong light irritates
11. Occasionally weak urine flow
12. Heart pounds after retiring
13. "Nervous" stomach
14. Appetite reduced occasionally
15. Cold sweats often
16. Get heated easily
17. Nerve discomfort
18. Staring, blink little
19. Sour stomach frequent
Group 2: *
1: MILD- occurs rarely
2: MODERATE- occurs several times a month
3: SEVERE- occurs almost constantly
Does not occur
1. Joint stiffness after arising
2. Muscle, leg, toe cramps at night
3. "Butterfly" stomach, cramps
4. Eyes or nose watery
5. Eyes blink often
6. Eyelids swollen, puffy
7. Indigestion soon after meals
8. Always seem hungry, feel "lightheaded" often
9. Digestion rapid
10. Vomit occasionally
11. Hoarseness frequent
12. Uneven breathing
13. Pulse slow
14. Gagging reflex slow
15. Difficulty swallowing
16. Temporary constipation or diarrhea
17. "Slow starter"
18. Get "chilled"
19. Perspire easily
Sensitive to cold
Upper respiratory challenges
Group 3: *
1: MILD- occurs rarely
2: MODERATE- occurs several times a month
3: SEVERE- occurs almost constantly
Does not occur
1. Eat when nervous
2. Excessive appetite
3. Hungry between meals
4. Irritable before meals
5. Get "shaky" if hungry
6. Fatigue, eating relieves
7. "Lightheaded" if meals delayed
8. Heart palpitates if meals missed or delayed
9. Fatigue in afternoon
10. Overeating sweets upsets
11. Awaken after few hours sleep, hard to get back to sleep
12. Crave candy or coffee in afternoon
13. Moods of "blues" or melancholy
14. Craving for sweets or snacks
Group 4: *
1. MILD- Occurs rarely
2. MODERATE- Occurs several times a month
3. SEVERE- Occurs almost constantly
Does not occur
Hands and feet go to sleep easily, numbness
Sighs frequently, "air hunger"
Aware of "breathing heavily"
High-altitude discomfort
Open windows in closed rooms
Immune system challenges
Afternoon "yawner"
Get "drowsy" often
Swollen ankles worse at night
Muscle cramps. worse during exercise; get "charley horse"
Difficulty catching breath, especially during exercise
Tightness or pressure in chest, worse on exertion
Skin discolors easily after impact
Tendency to anemia
Noises in head or "ringing in ears"
Fatigue upon exertion
Group 5: *
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
Dizziness
Dry skin
Burning feet
Blurred vision
Itching skin and feet
Hair loss
Occasional skin rashes
Bitter, metallic taste in mouth in morning
Occasional constipation
Worrier, feels insecure
Nausea occasionally after eating
Greasy foods upset
Stools light-colored
Skin peels on foot soles
Discomfort between shoulder blades
Occasional laxative use
Stools alternate from soft to watery
Sneezing attacks
Dreaming, nightmare-type bad dreams
Bad breath (halitosis)
Milk products cause upset
Sensitive to hot weather
Burning or itching anus
Crave sweets
Group 6: *
1. MILD- Occurs rarely
2. MODERATE- Occurs several times a month
3. SEVERE- Occurs almost constantly
Does not occur
Loss of taste for meat
Lower bowel gas several hours after eating
Burning stomach sensations, eating releaves
Coated tongue
Pass large amounts of foul-smelling gas
Indigestion 1/2-1 hour after eating; may be up to 3-4 hours after
Watery or loose stool
Gas shortly after eating
Stomach "bloating"
Group 7A: *
1. MILD- Occurs rarely
2. MODERATE- Occurs several times a month
3. SEVERE- Occurs almost constantly
Does not occur
1. Difficulty sleeping
2. On edge
3. Can't gain weight
4. Intolerance to heat
5. Highly emotional
6. Flush easily
7. Night sweats
8. Thin, moist skin
9. Inward trembling
10. Heart races
11. Increased appetite without weight gain
12. Pulse fast at rest
13. Eyelids and face twitch
14. Irritable and restless
15. Can't work under pressure
Group 7B: *
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
Increase in weight
Decrease in appetite
Fatigue easily
Ringing in ears
Sleepy during day
Sensitive to cold
Dry or scaly skin
Temporary constipation
Mental sluggishness
Hair coarse, falls out
Tension in head upon arising wears off during day
Slow pulse below 65
Changing urinary function
Sounds appear diminished
Reduced initiative
Group 7C: *
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
1. Failing memory with age
2. Increased sex drive
3. Episodes of tension in head
4. Decreased sugar intolerance
7D: *
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE-occurs almost constantly
Does not occur
1. Abnormal thirst
2. Bloating of abdomen
3. Weight gain around hips or waist
4. Sex drive reduced or lacking
5. Tendency for stomach issues
6. Immune system challenges
7. Menstrual disorders
7E: *
1. MILD-occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
1. Dizziness
2. Headaches
3. Hot flashes
4. Hair growth on face or body (female)
5. Sugar in urine (not diabetes)
6. Masculine tendencies (female)
7F: *
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
1. Weakness, dizziness
2. Tired throughout the day
3. Nails weak, ridged
4. Sensitive skin
5. Stiff joints
6. Perspiration increase
7. Bowel discomfort
8. Poor circulation
9. Swollen ankles
10. Crave salt
11. Areas of skin darkening
12. Upper respiratory sensitivity
13. Tiredness
14. Breathing challenges
Group 8: *
1. MILD-occurs rarely
2. MODERATE-occurs several times a month
3. SEVERE-occurs almost constantly
Does not occur
1. Muscle weakness
2. Lack of stamina
3. Drowsiness after eating
4. Muscular soreness
5. Heart races
6. Hyperirritable
7. Feeling of band around head
8. Melancholia (feeling of sadness)
9. Swelling of ankles
10. Change in urinary function
11. Tendency to consume sweets/carbohydrates
12. Muscle spasm
13. Blurred vision
14. Involuntary muscle action
15. Numbness
16. Night sweats
17. Rapid digestion
18. Sensitivity to noise
19. Redness of palms of hands and bottom of feet
20. Visible veins on chest and abdomen
21. Hemorrhoids
22. Apprehension (feeling that something bad is going to happen)
23. Nervousness causing loss of appetite
24. Nervousness with indigestion
25. Gastritis
26. Forgetfulness
27. Thinning hair
FEMALE ONLY
1. MILD- Occurs rarely
2. MODERATE- Occurs several times a month
3. SEVERE- Occurs almost constantly
Does not occur
1. Very easily fatigues
2. Premenstrual tension
3. Menses more painful than usual
4. Depressed feelings before menstruation
5. Painful breasts during menses
6. Menstruate too frequently
7. Hysterectomy/ovaries removed
8. Menopausal hot flashes
9. Menses scanty or missed
10. Acne, worse at menses
Clear selection
MALE ONLY
1. MILD- occurs rarely
2. MODERATE- occurs several times a month
3. SEVERE- occurs almost constantly
Does not occur
1. Less involved in exercise/social activities
2. Difficult to postpone urination
3. Weak urinary stream
4. Feeling of "blues" or melancholy
5. Feeling of incomplete bowel evacuation
6. Lack of energy
7. Muscles in arms and legs seem softer/smaller
8. Tire too easily
9. Avoid activity
10. Leg nervousness at night
11. Diminished sex drive
Clear selection
Please list the five main physical complaints you have in order of their importance: *
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