INSTRUCTIONS: Circle the number that applies to you. If a symptom does not apply, don’t circle anything for that symptom. First Name Last Name Email LevelDescription 1MILD symptom (occurs rarely) 2MODERATE symptom (occurs several times a month) 3SEVERE symptom (occurs almost constantly) GROUP 1 1.Acid foods upset123X 2.Get chilled often123X 3.“Lump” in throat123X 4.Dry mouth, eyes, nose123X 5.Pulse speeds after meal123X 6.Keyed up, fail to calm123X 7.Gag occasionally123X 8.Unable to relax, startle easily123X 9.Extremities cold, clammy123X 10.Strong light irritates123X 11.Occasionally weak urine flow123X 12.Heart pounds after retiring123X 13.“Nervous” stomach123X 14.Appetite reduced occasionally123X 15.Cold sweats often123X 16.Get heated easily123X 17.Nerve discomfort123X 18.Staring, blink little123X 19.Sour stomach frequent123X GROUP 2 20.Joint stiffness after arising123X 21.Muscle, leg, toe cramps at night123X 22.“Butterfly” stomach, cramps123X 23.Eyes or nose watery123X 24.Eyes blink often123X 25.Eyelids swollen, puffy123X 26.Indigestion soon after meals123X 27.Always seem hungry, feel “lightheaded” often123X 28.Digestion rapid123X 29.Vomit occasionally123X 30.Hoarseness frequent123X 31.Uneven breathing123X 32.Pulse slow123X 33.Gagging reflex slow123X 34.Difficulty swallowing123X 35.Temporary constipation or diarrhea123X 36.“Slow starter”123X 37.Get “chilled”123X 38.Perspire easily123X 39.Sensitive to cold123X 40.Upper respiratory challenges123X GROUP 3 41.Eat when nervous123X 42.Excessive appetite123X 43.Hungry between meals123X 44.Irritable before meals123X 45.Get “shaky” if hungry123X 46.Fatigue, eating relieves123X 47.“Lightheaded” if meals delayed123X 48.Heart palpitates if meals missed or delayed123X 49.Fatigue in afternoon123X 50.Overeating sweets upsets123X 51.Awaken after few hours sleep, hard to get back to sleep123X 52.Crave candy or coffee in afternoon123X 53.Moods of “blues” or melancholy123X 54.Craving for sweets or snacks123X GROUP 4 55.Hands and feet go to sleep easily, numbness123X 56.Sigh frequently, “air hunger”123X 57.Aware of “breathing heavily”123X 58.High-altitude discomfort123X 59.Open windows in closed room123X 60.Immune system challenges123X 61.Afternoon “yawner”123X 62.Get “drowsy” often123X 63.Swollen ankles worse at night123X 64.Muscle cramps, worse during exercise; get “charley horse”123X 65.Difficulty catching breath, especially during exercise123X 66.Tightness or pressure in chest, worse on exertion123X 67.Skin discolors easily after impact123X 68.Tendency to anemia123X 69.Noises in head or “ringing”123X 70.Fatigue upon exertion123X GROUP 5 71.Dizziness123X 72.Dry skin123X 73.Burning feet123X 74.Blurred vision123X 75.Itching skin and feet123X 76.Hair loss123X 77.Occasional skin rashes123X 78.Bitter, metallic taste in mouth in morning123X 79.Occasional constipation123X 80.Worrier, feels insecure123X 81.Nausea occasionally after eating123X 82.Greasy foods upset123X 83.Stools light-colored123X 84.Skin peels on foot soles123X 85.Discomfort between shoulder blades123X 86.Occasional laxative use123X 87.Stools alternate from soft to watery123X/span> 88.Sneezing attacks123X 89.Dreaming, nightmare-type bad dreams123X 90.Bad breath (halitosis)123X 91.Milk products cause upset123X 92.Sensitive to hot weather123X 93.Burning or itching anus123X 94.Crave sweets123X GROUP 6 95.Loss of taste for meat123X 96.Lower bowel gas several hours after eating123X 97.Burning stomach sensations, eating relieves123X 98.Coated tongue123X 99.Pass large amounts of foul-smelling gas123X 100.Indigestion ½-1 hour after eating; may be up to 3-4 hours after123X 101.Watery or loose stool123X 102.Gas shortly after eating123X 103.Stomach “bloating”123X GROUP 7a 104.Difficulty sleeping123X 105.On edge123X 106.Can’t gain weight123X 107.Intolerance to heat123X 108.Highly emotional123X 109.Flush easily123X 110.Night sweats123X 111.Thin, moist skin123X 112.Inward trembling123X 113.Heart races123X 114.Increased appetite without weight gain123X 115.Pulse fast at rest123X 116.Eyelids and face twitch123X 117.Irritable and restless123X 118.Can’t work under pressure123X GROUP 7b 119.Increase in weight123X 120.Decrease in appetite123X 121.Fatigue easily123X 122.Ringing in ears123X 123.Sleepy during day123X 124.Sensitive to cold123X 125.Dry or scaly skin123X 126.Temporary constipation123X 127.Mental sluggishness123X 128.Hair coarse, falls out123X 129.Tension in head upon arising wears off during day123X 130.Slow pulse below 65123X 131.Changing urinary function123X 132.Sounds appear diminished123X 133.Reduced initiative123X GROUP 7c 134.Failing memory with age123X 135.Increased sex drive123X 136.Episodes of tension in head123X 137.Decreased sugar tolerance123X GROUP 7d 138.Abnormal thirst123X 139.Bloating of abdomen123X 140.Weight gain around hips or waist123X 141.Sex drive reduced or lacking123X 142.Tendency for stomach issues123X 143.Immune system challenges123X 144.Menstrual disorders123X GROUP 7E 145.Dizziness123X 146.Headaches123X 147.Hot flashes123X 148.Hair growth on face or body (female)123X 149.Sugar in urine (not diabetes)123X 150.Masculine tendencies (female)123X GROUP 7F 151.Weakness, dizziness123X 152.Tired throughout day123X 153.Nails weak, ridged123X 154.Sensitive skin123X 155.Stiff joints123X 156.Perspiration increase123X 157.Bowel discomfort123X 158.Poor circulation123X 159.Swollen ankles123X 160.Crave salt123X 161.Areas of skin darkening123X 162.Upper respiratory sensitivity123X 163.Tiredness123X 164.Breathing challenges123X GROUP 8 165.Muscle weakness123X 166.Lack of stamina123X 167.Drowsiness after eating123X 168.Muscular soreness123X 169.Heart races123X 170.Hyperirritable123X 171.Feeling of a band around head123X 172.Melancholia (feeling of sadness)123X 173.Swelling of ankles123X 174.Change in urinary function123X 175.Tendency to consume sweets/carbohydrates123X 176.Muscle spasms123X 177.Blurred vision123X 178.Involuntary muscle action123X 179.Numbness123X 180.Night sweats123X 181.Rapid digestion123X 182.Sensitivity to noise123X 183.Redness of palms of hands and bottom of feet123X 184.Visible veins on chest and abdomen123X 185.Hemorrhoids123X 186.Apprehension (feeling that something bad is going to happen)123X 187.Nervousness causing loss of appetite123X 188.Nervousness with indigestion123X 189.Gastritis123X 190.Forgetfulness123X 191.Thinning hair123X FEMALE ONLY 192.Very easily fatigued123X 193.Premenstrual tension123X 194.Menses more painful than usual123X 195.Depressed feelings before menstruation123X 196.Painful breasts during menstruation123X 197.Menstruate too frequently123X 198.Hysterectomy/ovaries removed123X 199.Menopausal hot flashes123X 200.Menses scanty or missed123X 201.Acne, worse at menses123X MALE ONLY 202.Less involved in exercise/social activities123X 203.Difficult to postpone urination123X 204.Weak urinary stream123X 205.Feeling of “blues” or melancholy123X 206.Feeling of incomplete bowel evacuation123X 207.Lack of energy123X 208.Muscles in arms and legs seem softer/smaller123X 209.Tire too easily123X 210.Avoid activity123X 211.Leg nervousness at night123X 212.Diminished sex drive123X