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System Survey

Complete only the symptoms that apply to you. Do not check any boxes if you do not experience the symptom.

Your results will be discussed at your next visit or emailed to you within 10 business days.

Step 1 of 10

10%

Name*
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Gender*
- Male
- Female
Email*
Date*
MM slash DD slash YYYY
Authorization*
I agree that by submitting this form, I am authorizing Living with Elevation to generate and email me a system survey report.
READ THIS BEFORE STARTING THE FORM*
I will only check boxes in the symptoms that apply to me. If it doesn't apply to me, I will leave the symptom boxes empty.
I understand
Group 1
1. Acid foods upset
- Mild
- Moderate
- Severe
- Doesn't apply to me
2. Get chilled often
- Mild
- Moderate
- Severe
- Doesn't apply to me
3. "Lump" in throat
- Mild
- Moderate
- Severe
- Doesn't apply to me
4. Dry mouth, eyes, nose
- Mild
- Moderate
- Severe
- Doesn't apply to me
5. Pulse speeds after meal
- Mild
- Moderate
- Severe
- Doesn't apply to me
6. Keyed up, fail to calm
- Mild
- Moderate
- Severe
- Doesn't apply to me
7. Gag occasionally
- Mild
- Moderate
- Severe
- Doesn't apply to me
8. Unable to relax, startle easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
9. Extremities cold, clammy
- Mild
- Moderate
- Severe
- Doesn't apply to me
10. Strong light irritates
- Mild
- Moderate
- Severe
- Doesn't apply to me
11. Occasionally weak urine flow
- Mild
- Moderate
- Severe
- Doesn't apply to me
12. Heart pounds after retiring
- Mild
- Moderate
- Severe
- Doesn't apply to me
13. "Nervous" stomach
- Mild
- Moderate
- Severe
- Doesn't apply to me
14. Appetite reduced occasionally
- Mild
- Moderate
- Severe
- Doesn't apply to me
15. Cold sweats often
- Mild
- Moderate
- Severe
- Doesn't apply to me
16. Get heated easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
17. Nerve discomfort
- Mild
- Moderate
- Severe
- Doesn't apply to me
18. Staring, blink little
- Mild
- Moderate
- Severe
- Doesn't apply to me
19. Sour stomach frequent
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 2
20. Joint stiffness after arising
- Mild
- Moderate
- Severe
- Doesn't apply to me
21. Muscle, legs, toe cramps at night
- Mild
- Moderate
- Severe
- Doesn't apply to me
22. "Butterfly" stomach, cramps
- Mild
- Moderate
- Severe
- Doesn't apply to me
23. Eyes or nose watery
- Mild
- Moderate
- Severe
- Doesn't apply to me
24. Eyes blink often
- Mild
- Moderate
- Severe
- Doesn't apply to me
25. Eyelids swollen, puffy
- Mild
- Moderate
- Severe
- Doesn't apply to me
26. Indigestion soon after meals
- Mild
- Moderate
- Severe
- Doesn't apply to me
27. Always seems hungry, feel "lightheaded often
- Mild
- Moderate
- Severe
- Doesn't apply to me
28. Digestion rapid
- Mild
- Moderate
- Severe
- Doesn't apply to me
29. Vomit occasionally
- Mild
- Moderate
- Severe
- Doesn't apply to me
30. Hoarseness frequent
- Mild
- Moderate
- Severe
- Doesn't apply to me
31. Uneven breathing
- Mild
- Moderate
- Severe
- Doesn't apply to me
32. Pulse slow
- Mild
- Moderate
- Severe
- Doesn't apply to me
33. Gagging reflex slow
- Mild
- Moderate
- Severe
- Doesn't apply to me
34. Difficulty swallowing
- Mild
- Moderate
- Severe
- Doesn't apply to me
35. Temporary constipation or diarrhea
- Mild
- Moderate
- Severe
- Doesn't apply to me
36. "Slow starter"
- Mild
- Moderate
- Severe
- Doesn't apply to me
37. Get "chilled"
- Mild
- Moderate
- Severe
- Doesn't apply to me
38. Perspire easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
39. Sensitive to cold
- Mild
- Moderate
- Severe
- Doesn't apply to me
40. Upper respiratory challenges
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 3
41. Eat when nervous
- Mild
- Moderate
- Severe
- Doesn't apply to me
42. Excessive appetite
- Mild
- Moderate
- Severe
- Doesn't apply to me
43. Hungry between meals
- Mild
- Moderate
- Severe
- Doesn't apply to me
44. Irritable before meals
- Mild
- Moderate
- Severe
- Doesn't apply to me
45. Get "shaky" if hungry
- Mild
- Moderate
- Severe
- Doesn't apply to me
46. Fatigue, eating relieves
- Mild
- Moderate
- Severe
- Doesn't apply to me
47. "Lightheaded" if meals delayed
- Mild
- Moderate
- Severe
- Doesn't apply to me
48. Heart palpitates if meals missed or delayed
- Mild
- Moderate
- Severe
- Doesn't apply to me
49. Fatigue in afternoon
- Mild
- Moderate
- Severe
- Doesn't apply to me
50. Overeating sweets upsets
- Mild
- Moderate
- Severe
- Doesn't apply to me
51. Awaken after few hours of sleep, hard to get back to sleep
- Mild
- Moderate
- Severe
- Doesn't apply to me
52. Crave candy or coffee in afternoon
- Mild
- Moderate
- Severe
- Doesn't apply to me
53. Moods of "blues" or melancholy
- Mild
- Moderate
- Severe
- Doesn't apply to me
54. Craving for sweets or snacks
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 4
55. Hands and feet go to sleep easily, numbness
- Mild
- Moderate
- Severe
- Doesn't apply to me
56. Sigh frequently, "air hunger"
- Mild
- Moderate
- Severe
- Doesn't apply to me
57. Aware of "breathing heavily"
- Mild
- Moderate
- Severe
- Doesn't apply to me
58. High-altitude discomfort
- Mild
- Moderate
- Severe
- Doesn't apply to me
59. Open windows in closed room
- Mild
- Moderate
- Severe
- Doesn't apply to me
60. Immune system challenges
- Mild
- Moderate
- Severe
- Doesn't apply to me
61. Afternoon "yawner"
- Mild
- Moderate
- Severe
- Doesn't apply to me
62. Get drowsy often
- Mild
- Moderate
- Severe
- Doesn't apply to me
63. Swollen ankles worse at night
- Mild
- Moderate
- Severe
- Doesn't apply to me
64. Muscle cramps, worse during exercise: get "charley horse"
- Mild
- Moderate
- Severe
- Doesn't apply to me
65. Difficulty catching breath, especially during exercise
- Mild
- Moderate
- Severe
- Doesn't apply to me
66. Tightness or pressure in chest, worse on exertion
- Mild
- Moderate
- Severe
- Doesn't apply to me
67. Skin discolors easily after impact
- Mild
- Moderate
- Severe
- Doesn't apply to me
68. Tendency to anemia
- Mild
- Moderate
- Severe
- Doesn't apply to me
69. Noise in head or "ringing in ears"
- Mild
- Moderate
- Severe
- Doesn't apply to me
70. Fatigue upon exertion
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 5
71. Dizziness
- Mild
- Moderate
- Severe
- Doesn't apply to me
72. Dry Skin
- Mild
- Moderate
- Severe
- Doesn't apply to me
73. Burning feet
- Mild
- Moderate
- Severe
- Doesn't apply to me
74. Blurred vision
- Mild
- Moderate
- Severe
- Doesn't apply to me
75. Itching skin and feet
- Mild
- Moderate
- Severe
- Doesn't apply to me
76. Hair loss
- Mild
- Moderate
- Severe
- Doesn't apply to me
77. Occasional skin rashes
- Mild
- Moderate
- Severe
- Doesn't apply to me
78. Bitter, metallic taste in mouth in morning
- Mild
- Moderate
- Severe
- Doesn't apply to me
79. Occasional constipation
- Mild
- Moderate
- Severe
- Doesn't apply to me
80. Worrier, feels insecure
- Mild
- Moderate
- Severe
- Doesn't apply to me
81. Nausea occasionally after eating
- Mild
- Moderate
- Severe
- Doesn't apply to me
82. Greasy foods upset
- Mild
- Moderate
- Severe
- Doesn't apply to me
83. Stools light-colored
- Mild
- Moderate
- Severe
- Doesn't apply to me
84. Skin peels on foot soles
- Mild
- Moderate
- Severe
- Doesn't apply to me
85. Discomfort between shoulder blades
- Mild
- Moderate
- Severe
- Doesn't apply to me
86. Occasional laxative use
- Mild
- Moderate
- Severe
- Doesn't apply to me
87. Stools alternate from soft to watery
- Mild
- Moderate
- Severe
- Doesn't apply to me
88. Sneezing attacks
- Mild
- Moderate
- Severe
- Doesn't apply to me
89. Dreaming, nightmare-type bad dreams
- Mild
- Moderate
- Severe
- Doesn't apply to me
90. Bad breath (halitosis)
- Mild
- Moderate
- Severe
- Doesn't apply to me
91. Milk products cause upset
- Mild
- Moderate
- Severe
- Doesn't apply to me
92. Sensitive to hot weather
- Mild
- Moderate
- Severe
- Doesn't apply to me
93. Burning or itching anus
- Mild
- Moderate
- Severe
- Doesn't apply to me
94. Crave sweets
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 6
95. Loss of taste for meat
- Mild
- Moderate
- Severe
- Doesn't apply to me
96. Lower bowel gas several hours after eating
- Mild
- Moderate
- Severe
- Doesn't apply to me
97. Burning stomach sensations, eating relieves
- Mild
- Moderate
- Severe
- Doesn't apply to me
98. Coated tongue
- Mild
- Moderate
- Severe
- Doesn't apply to me
99. Pass large amounts of foul-smelling gas
- Mild
- Moderate
- Severe
- Doesn't apply to me
100. Indigestion 1/2-1 hour after eating, may be up to 3-4 hours after
- Mild
- Moderate
- Severe
- Doesn't apply to me
101. Watery or loose stool
- Mild
- Moderate
- Severe
- Doesn't apply to me
102. Gas shortly after eating
- Mild
- Moderate
- Severe
- Doesn't apply to me
103. Stomach "bloating"
- Mild
- Moderate
- Severe
- Doesn't apply to me
Group 7A
104. Difficulty sleeping
- Mild
- Moderate
- Severe
- Doesn't apply to me
105. On edge
- Mild
- Moderate
- Severe
- Doesn't apply to me
106. Can't gain weight
- Mild
- Moderate
- Severe
- Doesn't apply to me
107. Intolerance to heat
- Mild
- Moderate
- Severe
- Doesn't apply to me
108. Highly emotional
- Mild
- Moderate
- Severe
- Doesn't apply to me
109. Flush easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
110. Night sweats
- Mild
- Moderate
- Severe
- Doesn't apply to me
111. Thin, moist skin
- Mild
- Moderate
- Severe
- Doesn't apply to me
112. Inward trembling
- Mild
- Moderate
- Severe
- Doesn't apply to me
113. Heart races
- Mild
- Moderate
- Severe
- Doesn't apply to me
114. Increased appetite without weight gain
- Mild
- Moderate
- Severe
- Doesn't apply to me
115. Pulse fast at rest
- Mild
- Moderate
- Severe
- Doesn't apply to me
116. Eyelids and face twitch
- Mild
- Moderate
- Severe
- Doesn't apply to me
117. Irritable and restless
- Mild
- Moderate
- Severe
- Doesn't apply to me
118. Can't work under pressure
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 7B
119. Increase in weight
- Mild
- Moderate
- Severe
- Doesn't apply to me
120. Decrease in appetite
- Mild
- Moderate
- Severe
- Doesn't apply to me
121. Fatigue easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
122. Ringing in ears
- Mild
- Moderate
- Severe
- Doesn't apply to me
123. Sleepy during day
- Mild
- Moderate
- Severe
- Doesn't apply to me
124. Sensitive to cold
- Mild
- Moderate
- Severe
- Doesn't apply to me
125. Dry or scaly skin
- Mild
- Moderate
- Severe
- Doesn't apply to me
126. Temporary constipation
- Mild
- Moderate
- Severe
- Doesn't apply to me
127. Mental sluggishness
- Mild
- Moderate
- Severe
- Doesn't apply to me
128. Hair coarse, falls out
- Mild
- Moderate
- Severe
- Doesn't apply to me
129. Tension in head upon arising, wears off during day
- Mild
- Moderate
- Severe
- Doesn't apply to me
130. Slow pulse below 65
- Mild
- Moderate
- Severe
- Doesn't apply to me
131. Changing urinary function
- Mild
- Moderate
- Severe
- Doesn't apply to me
132. Sounds appear diminished
- Mild
- Moderate
- Severe
- Doesn't apply to me
133. Reduced initiative
- Mild
- Moderate
- Severe
- Doesn't apply to me
Group 7C
134. Failing memory with age
- Mild
- Moderate
- Severe
- Doesn't apply to me
135. Increased sex drive
- Mild
- Moderate
- Severe
- Doesn't apply to me
136. Episodes of tension in head
- Mild
- Moderate
- Severe
- Doesn't apply to me
137. Decreased sugar tolerance
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 7D
138. Abnormal thirst
- Mild
- Moderate
- Severe
- Doesn't apply to me
139. Bloating of abdomen
- Mild
- Moderate
- Severe
- Doesn't apply to me
140. Weight gain around hips or waist
- Mild
- Moderate
- Severe
- Doesn't apply to me
141. Sex drive reduced or lacking
- Mild
- Moderate
- Severe
- Doesn't apply to me
142. Tendency for stomach issues
- Mild
- Moderate
- Severe
- Doesn't apply to me
143. Immune system challenges
- Mild
- Moderate
- Severe
- Doesn't apply to me
144. Menstrual disorders
- Mild
- Moderate
- Severe
- Doesn't apply to me
Group 7E
145. Dizziness
- Mild
- Moderate
- Severe
- Doesn't apply to me
146. Headaches
- Mild
- Moderate
- Severe
- Doesn't apply to me
147. Hot flashes
- Mild
- Moderate
- Severe
- Doesn't apply to me
148. Hair growth on face or body (female)
- Mild
- Moderate
- Severe
- Doesn't apply to me
149. Sugar in urine (not diabetes)
- Mild
- Moderate
- Severe
- Doesn't apply to me
150. Masculine tendencies (female)
- Mild
- Moderate
- Severe
- Doesn't apply to me
Group 7F
151. Weakness, dizziness
- Mild
- Moderate
- Severe
- Doesn't apply to me
152. Tired throughout day
- Mild
- Moderate
- Severe
- Doesn't apply to me
153. Nails weak, ridged
- Mild
- Moderate
- Severe
- Doesn't apply to me
154. Sensitive skin
- Mild
- Moderate
- Severe
- Doesn't apply to me
155. Stiff joints
- Mild
- Moderate
- Severe
- Doesn't apply to me
156. Perspiration increase
- Mild
- Moderate
- Severe
- Doesn't apply to me
157. Bowel discomfort
- Mild
- Moderate
- Severe
- Doesn't apply to me
158. Poor circulation
- Mild
- Moderate
- Severe
- Doesn't apply to me
159. Swollen ankles
- Mild
- Moderate
- Severe
- Doesn't apply to me
160. Crave salt
- Mild
- Moderate
- Severe
- Doesn't apply to me
161. Areas of skin darkening
- Mild
- Moderate
- Severe
- Doesn't apply to me
162. Upper respiratory sensitivity
- Mild
- Moderate
- Severe
- Doesn't apply to me
163. Tiredness
- Mild
- Moderate
- Severe
- Doesn't apply to me
164. Breathing challenges
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Group 8
165. Muscle weakness
- Mild
- Moderate
- Severe
- Doesn't apply to me
166. Lack of stamina
- Mild
- Moderate
- Severe
- Doesn't apply to me
167. Drowsiness after eating
- Mild
- Moderate
- Severe
- Doesn't apply to me
168. Muscular soreness
- Mild
- Moderate
- Severe
- Doesn't apply to me
169. Heart races
- Mild
- Moderate
- Severe
- Doesn't apply to me
170. Hyper-irritable
- Mild
- Moderate
- Severe
- Doesn't apply to me
171. Feeling of band around head
- Mild
- Moderate
- Severe
- Doesn't apply to me
172. Melancholia (feeling of sadness)
- Mild
- Moderate
- Severe
- Doesn't apply to me
173. Swelling of ankles
- Mild
- Moderate
- Severe
- Doesn't apply to me
174. Change in urinary function
- Mild
- Moderate
- Severe
- Doesn't apply to me
175. Tendency to consume sweets/carbohydrates
- Mild
- Moderate
- Severe
- Doesn't apply to me
176. Muscle spasms
- Mild
- Moderate
- Severe
- Doesn't apply to me
177. Blurred vision
- Mild
- Moderate
- Severe
- Doesn't apply to me
178. Involuntary muscle action
- Mild
- Moderate
- Severe
- Doesn't apply to me
179. Numbness
- Mild
- Moderate
- Severe
- Doesn't apply to me
180. Night sweats
- Mild
- Moderate
- Severe
- Doesn't apply to me
181. Rapid digestion
- Mild
- Moderate
- Severe
- Doesn't apply to me
182. Sensitivity to noise
- Mild
- Moderate
- Severe
- Doesn't apply to me
183. Redness of palms of hands and bottom of feet
- Mild
- Moderate
- Severe
- Doesn't apply to me
184. Visible veins on chest and abdomen
- Mild
- Moderate
- Severe
- Doesn't apply to me
185. Hemorrhoids
- Mild
- Moderate
- Severe
- Doesn't apply to me
186. Apprehension (feeling that something bad is going to happen)
- Mild
- Moderate
- Severe
- Doesn't apply to me
187. Nervousness causing loss of appetite
- Mild
- Moderate
- Severe
- Doesn't apply to me
188. Nervousness with indigestion
- Mild
- Moderate
- Severe
- Doesn't apply to me
189. Gastritis
- Mild
- Moderate
- Severe
- Doesn't apply to me
190. Forgetfulness
- Mild
- Moderate
- Severe
- Doesn't apply to me
191. Thinning hair
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

Female Only
192. Very easily fatigued
- Mild
- Moderate
- Severe
- Doesn't apply to me
193. Premenstrual tension
- Mild
- Moderate
- Severe
- Doesn't apply to me
194. Menses more painful than usual
- Mild
- Moderate
- Severe
- Doesn't apply to me
195. Depressed feelings before menstruation
- Mild
- Moderate
- Severe
- Doesn't apply to me
196. Painful breasts during menses
- Mild
- Moderate
- Severe
- Doesn't apply to me
197. Menstruate too frequently
- Mild
- Moderate
- Severe
- Doesn't apply to me
198. Hysterectomy/ovaries removed
- Mild
- Moderate
- Severe
- Doesn't apply to me
199. Menopausal hot flashes
- Mild
- Moderate
- Severe
- Doesn't apply to me
200. Menses scanty or missed
- Mild
- Moderate
- Severe
201. Acne, worse at menses
- Mild
- Moderate
- Severe
- Doesn't apply to me
Male Only
202. Less involved in exercise/social activities
- Mild
- Moderate
- Severe
- Doesn't apply to me
203. Difficult to postpone urination
- Mild
- Moderate
- Severe
- Doesn't apply to me
204. Weak urinary stream
- Mild
- Moderate
- Severe
- Doesn't apply to me
205. Feeling of "blues" or melancholy
- Mild
- Moderate
- Severe
- Doesn't apply to me
206. Feeling of incomplete bowel evacuation
- Mild
- Moderate
- Severe
- Doesn't apply to me
207. Lack of energy
- Mild
- Moderate
- Severe
- Doesn't apply to me
208. Muscles in arms and legs seem softer/smaller
- Mild
- Moderate
- Severe
- Doesn't apply to me
209. Tire too easily
- Mild
- Moderate
- Severe
- Doesn't apply to me
210. Avoid activity
- Mild
- Moderate
- Severe
- Doesn't apply to me
211. Leg nervousness at night
- Mild
- Moderate
- Severe
- Doesn't apply to me
212. Diminished sex drive
- Mild
- Moderate
- Severe
- Doesn't apply to me

Save and Continue Later

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Living with Elevation Natural Health Center
April Martinez, ND
313 4th St, Rawlins WY 82301
307-328-5800
Copyright 2018 Living With Elevation, LLC.

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