“something The following symptoms are used as guidance and not viewed as wrong.” If you experience any of the symptoms presently (or in the recent past), please mark by indicating past or present, frequently or infrequently: Digestion Eat when nervous Irritable before meals Acid foods upset Fatigue relieved by eating Bad breath Afternoon headaches Burning stomach relieved by eating (excess) Wake in night and can’t get back to sleep (adrenal) Stomach bloating Moods of depression Lower bowel gas after eating Crave sweets Foul smelling gas Headaches upon rising; wear off during day Indigestion soon after eating Diabetes Frequent sour stomach Loss of taste for meat Cardiac/Circulation Frequent vomiting (excess) Greasy upset Swollen ankles worse at night Nervous stomach Bruise easily Queasy with headache over eyes Ringing in ears Tension/tightness under sternum Elimination Dizziness High Blood Pressure Burning/itching anus (parasites/food sensitivity) Low Blood Pressure Alternating constipation/diarrhea Varicose Veins : Location__________ Stools soft and/or watery Headaches: Cluster/migraines/tension Irritable bowel Use of laxatives Muscles/Joints/Skeletal Painful bowel movements Painful joints GI ulcers Low back ache Stools light colored Upper back ache Boils Fibromyalgia Fungus Sciatica Acne Spinal problems Psoriasis Artificial limbs Itching Arthritic Respiratory disorders Endocrine Viscera Get chilled often Cold hands/feet Painful breasts Flush easily Skin peels on foot soles Irritated by strong light Difficulty swallowing Slow to wake and get started Bitter, metallic taste in mouth in mornings Perspire easily Pain between shoulder blades Sigh frequently Gall stones Get drowsy Mental sluggishness Blood Sugar Chronic fatigue Salt craving Excessive appetite Unable to Lightheaded & feeling of hunger Startle easily Get shaky if hungry Tendency to asthma/allergies
The following symptoms are used as guidance and not viewed as “something wrong.” If you experience any of the symptoms presently (or in the recent past), please mark by indicating past or present, frequently or infrequently: Digestion Acid foods upset Bad breath Burning stomach relieved by eating (excess) Stomach bloating Lower bowel gas after eating Foul smelling gas Indigestion soon after eating Frequent sour stomach Loss of taste for meat Frequent vomiting (excess) Greasy upset Nervous stomach Queasy with headache over eyes Elimination Burning/itching anus (parasites/food sensitivity) Alternating constipation/diarrhea Stools soft and/or watery Irritable bowel Use of laxatives Painful bowel movements GI ulcers Stools light colored Boils Fungus Acne Psoriasis Itching Respiratory disorders Viscera Painful breasts Skin peels on foot soles Difficulty swallowing Bitter, metallic taste in mouth in mornings Pain between shoulder blades Gall stones Blood Sugar Excessive appetite Lightheaded & feeling of hunger Get shaky if hungry Eat when nervous Irritable before meals Fatigue relieved by eating Afternoon headaches Wake in night and can’t get back to sleep (adrenal) Moods of depression Crave sweets Headaches upon rising; wear off during day Diabetes Cardiac/Circulation Swollen ankles worse at night Bruise easily Ringing in ears Tension/tightness under sternum Dizziness High Blood Pressure Low Blood Pressure Varicose Veins : Location__________ Headaches: Cluster/migraines/tension Muscles/Joints/Skeletal Painful joints Low back ache Upper back ache Fibromyalgia Sciatica Spinal problems Artificial limbs Arthritic Endocrine Get chilled often Cold hands/feet Flush easily Irritated by strong light Slow to wake and get started Perspire easily Sigh frequently Get drowsy Mental sluggishness Chronic fatigue Salt craving Unable to Startle easily Tendency to asthma/allergies
ConfidentialIntakeFormDigestion2017.docx