INSTRUCTIONS: Circle the number that applies to you. If a symptom does not apply, don’t circle anything for that symptom.

LevelDescription
1 MILD symptom (occurs rarely)
2MODERATE symptom (occurs several times a month)
3SEVERE symptom (occurs almost constantly)
LevelDescription
1MILD symptom (occurs rarely)
2MODERATE symptom (occurs several times a month)
3SEVERE symptom (occurs almost constantly)

GROUP 1

1.Acid foods upsetX
2.Get chilled oftenX
3.“Lump” in throatX
4.Dry mouth, eyes, noseX
5.Pulse speeds after mealX
6.Keyed up, fail to calmX
7.Gag occasionallyX
8.Unable to relax, startle easilyX
9.Extremities cold, clammyX
10.Strong light irritatesX
11.Occasionally weak urine flowX
12.Heart pounds after retiringX
13.“Nervous” stomachX
14.Appetite reduced occasionallyX
15.Cold sweats oftenX
16.Get heated easilyX
17.Nerve discomfortX
18.Staring, blink littleX
19.Sour stomach frequentX

GROUP 2

20.Joint stiffness after arisingX
21.Muscle, leg, toe cramps at nightX
22.“Butterfly” stomach, crampsX
23.Eyes or nose wateryX
24.Eyes blink oftenX
25.Eyelids swollen, puffyX
26.Indigestion soon after mealsX
27.Always seem hungry, feel “lightheaded” oftenX
28.Digestion rapidX
29.Vomit occasionallyX
30.Hoarseness frequentX
31.Uneven breathingX
32.Pulse slowX
33.Gagging reflex slowX
34.Difficulty swallowingX
35.Temporary constipation or diarrheaX
36.“Slow starter”X
37.Get “chilled”X
38.Perspire easilyX
39.Sensitive to coldX
40.Upper respiratory challengesX

GROUP 3

41.Eat when nervousX
42.Excessive appetiteX
43.Hungry between mealsX
44.Irritable before mealsX
45.Get “shaky” if hungryX
46.Fatigue, eating relievesX
47.“Lightheaded” if meals delayedX
48.Heart palpitates if meals missed or delayedX
49.Fatigue in afternoonX
50.Overeating sweets upsetsX
51.Awaken after few hours sleep, hard to get back to sleepX
52.Crave candy or coffee in afternoonX
53.Moods of “blues” or melancholyX
54.Craving for sweets or snacksX

GROUP 4

55.Hands and feet go to sleep easily, numbnessX
56.Sigh frequently, “air hunger”X
57.Aware of “breathing heavily”X
58.High-altitude discomfortX
59.Open windows in closed roomX
60.Immune system challengesX
61.Afternoon “yawner”X
62.Get “drowsy” oftenX
63.Swollen ankles worse at nightX
64.Muscle cramps, worse during exercise; get “charley horse”X
65.Difficulty catching breath, especially during exerciseX
66.Tightness or pressure in chest, worse on exertionX
67.Skin discolors easily after impactX
68.Tendency to anemiaX
69.Noises in head or “ringing”X
70.Fatigue upon exertionX

GROUP 5

71.DizzinessX
72.Dry skinX
73.Burning feetX
74.Blurred visionX
75.Itching skin and feetX
76.Hair lossX
77.Occasional skin rashesX
78.Bitter, metallic taste in mouth in morningX
79.Occasional constipationX
80.Worrier, feels insecureX
81.Nausea occasionally after eatingX
82.Greasy foods upsetX
83.Stools light-coloredX
84.Skin peels on foot solesX
85.Discomfort between shoulder bladesX
86.Occasional laxative useX
87.Stools alternate from soft to wateryX/span>
88.Sneezing attacksX
89.Dreaming, nightmare-type bad dreamsX
90.Bad breath (halitosis)X
91.Milk products cause upsetX
92.Sensitive to hot weatherX
93.Burning or itching anusX
94.Crave sweetsX

GROUP 6

95.Loss of taste for meatX
96.Lower bowel gas several hours after eatingX
97.Burning stomach sensations, eating relievesX
98.Coated tongueX
99.Pass large amounts of foul-smelling gasX
100.Indigestion ½-1 hour after eating; may be up to 3-4 hours afterX
101.Watery or loose stoolX
102.Gas shortly after eatingX
103.Stomach “bloating”X

GROUP 7a

104.Difficulty sleepingX
105.On edgeX
106.Can’t gain weightX
107.Intolerance to heatX
108.Highly emotionalX
109.Flush easilyX
110.Night sweatsX
111.Thin, moist skinX
112.Inward tremblingX
113.Heart racesX
114.Increased appetite without weight gainX
115.Pulse fast at restX
116.Eyelids and face twitchX
117.Irritable and restlessX
118.Can’t work under pressureX

GROUP 7b

119.Increase in weightX
120.Decrease in appetiteX
121.Fatigue easilyX
122.Ringing in earsX
123.Sleepy during dayX
124.Sensitive to coldX
125.Dry or scaly skinX
126.Temporary constipationX
127.Mental sluggishnessX
128.Hair coarse, falls outX
129.Tension in head upon arising wears off during dayX
130.Slow pulse below 65X
131.Changing urinary functionX
132.Sounds appear diminishedX
133.Reduced initiativeX

GROUP 7c

134.Failing memory with ageX
135.Increased sex driveX
136.Episodes of tension in headX
137.Decreased sugar toleranceX

GROUP 7d

138.Abnormal thirstX
139.Bloating of abdomenX
140.Weight gain around hips or waistX
141.Sex drive reduced or lackingX
142.Tendency for stomach issuesX
143.Immune system challengesX
144.Menstrual disordersX

GROUP 7E

145.DizzinessX
146.HeadachesX
147.Hot flashesX
148.Hair growth on face or body (female)X
149.Sugar in urine (not diabetes)X
150.Masculine tendencies (female)X

GROUP 7F

151.Weakness, dizzinessX
152.Tired throughout dayX
153.Nails weak, ridgedX
154.Sensitive skinX
155.Stiff jointsX
156.Perspiration increaseX
157.Bowel discomfortX
158.Poor circulationX
159.Swollen anklesX
160.Crave saltX
161.Areas of skin darkeningX
162.Upper respiratory sensitivityX
163.TirednessX
164.Breathing challengesX

GROUP 8

165.Muscle weaknessX
166.Lack of staminaX
167.Drowsiness after eatingX
168.Muscular sorenessX
169.Heart racesX
170.HyperirritableX
171.Feeling of a band around headX
172.Melancholia (feeling of sadness)X
173.Swelling of anklesX
174.Change in urinary functionX
175.Tendency to consume sweets/carbohydratesX
176.Muscle spasmsX
177.Blurred visionX
178.Involuntary muscle actionX
179.NumbnessX
180.Night sweatsX
181.Rapid digestionX
182.Sensitivity to noiseX
183.Redness of palms of hands and bottom of feetX
184.Visible veins on chest and abdomenX
185.HemorrhoidsX
186.Apprehension (feeling that something bad is going to happen)X
187.Nervousness causing loss of appetiteX
188.Nervousness with indigestionX
189.GastritisX
190.ForgetfulnessX
191.Thinning hairX

FEMALE ONLY

192.Very easily fatiguedX
193.Premenstrual tensionX
194.Menses more painful than usualX
195.Depressed feelings before menstruationX
196.Painful breasts during menstruationX
197.Menstruate too frequentlyX
198.Hysterectomy/ovaries removedX
199.Menopausal hot flashesX
200.Menses scanty or missedX
201.Acne, worse at mensesX

MALE ONLY

202.Less involved in exercise/social activitiesX
203.Difficult to postpone urinationX
204.Weak urinary streamX
205.Feeling of “blues” or melancholyX
206.Feeling of incomplete bowel evacuationX
207.Lack of energyX
208.Muscles in arms and legs seem softer/smallerX
209.Tire too easilyX
210.Avoid activityX
211.Leg nervousness at nightX
212.Diminished sex driveX