Free 

Nutritional  Symptom  Survey

Congradulations, for taking the time and interest in your health. This Nutritional Symptom Survey has been used by doctors and health professionals for over sixty years. The purpose of this survey is to evaluate the nutritional needs of your body organs, glands and systems that could be creating a wide range of physical or mental symptoms due to nutritional imbalances somewhere in the body.

This symptom survey provides you with a detailed three step report of your current nutritional needs to balance your entire body/mind system.

Step One: It prioritizes by percentages specific areas of the body that need nutritional to balance and support the entire body/mind system.                            

Step Two: Provides a detailed list indicating what percentage of a body system is being affected by the nutritional imbalance.                                          

Step Three: Listing of nutritional supplements needed with specific dosages to correct the imbalances.

Step Four:  Gives you the cost for a one week supply, two week supply and monthly supply .

 What To Do Next ?

Just fill in the symptom survey below, after completion of the survey click the box at the bottom to accept our privacy policy then click submit. Body Expressions will contact you with your test results & reports along with information on how to order the supplements you need based on the information you provide below.

MUST READ INSTRUCTIONS:  before entering your symptoms:

Enter the number of symptom occurance 1-2-3 after each symptom that best describes your condition:

1 = mild.   This symptom occures once or twice a month.  

2 = moderate.  This symptom occures one to three times a week

3 = severe.  This symptom occures daily.

 Blank =  This symptom does not apply to me.

Only enter 1, 2, or 3 in the space provided. Leave the section blank if it does not apply.

* YOU MUST FILL IN THIS FIELD BELOW.

 

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1. Acid foods upset
2. Feel chilled often
3. "Lump" in throat
4. Dry mouth-eyes-nose
5. Pulse speeds after meals
6. Keyed up; unable to feel calm
7. Cuts heal slowly
8. Gag easily
9. Unable to relax; startles easily
10. Extremities cold and/or clammy
11. Strong light irritates
12. Urine amount reduced
13. Heart pounds after retiring
14. "Nervous" stomach
15. Appetite reduced
16. Cold sweats often
17. Body temperature rises easily
18. Skin sensitive to touch
19. Staring blinks little
20. Frequently have sour stomach
21. Joint stiffness after arising
22. Muscle-leg-toe cramps at night
23. "Butterfly" stomach, cramps
24. Eyes or nose watery
25. Eyes blink often
26. Eyelids swollen or puffy
27. Indigestion soon after meals
28. Always seem hungry; "lightheaded" often
29. Food digest rapidly
30. Vomit freqently
31. Frequently hoarse
32. Irregular breathing
33. Pulse slow or feels "irregular"
34. Slow gag reflex
35. Difficulty swallowing
36. Alternating constipation and diarrhea
37. "Slow starter"
38. Not easily chilled
39. Perspire easily
40. Poor circulation or sensitive to cold
41. Subject to colds, asthma, bronchitis
42. Eat when nervous
43. Excessive appetite
44. Hungry between meals
45. Irritable before meals
46. Get "shaky" if hungry
47. Feeling fatigued, eating relieves
48. "Lightheaded" if meals delayed
49. Heart palpitates if meals missed or delayed
50. Afternoon headaches
51. Upset feeling from excessive eating of sweets
52. Awaken after a few hours sleep, hard to get back to sleep
53. Crave candy or coffe in afternoons
54. Moods of depression, "blues" or melancholy
55. Abnormal craving for sweets or snacks
56. Hands and fee go th sleep easily, numbness
57. Sign frequently "air hunger"
58. Aware of "breathing heavily"
59. Discomfort at high altitude
60. Opens windows in closed room
61. Susceptible to colds and fevers
62. Afternoon "yawner"
63. Get "drowsy" often
64. Swollen ankles worse at night
65. Muscle cramps, worse during exercise; "charley-horses"
66. Shortness of breath on exertion
67. Dull pain in chest or radiating into left arm, gets worse on exertion
68. Bruise easily, "black/blue" spots on arms or legs
69. Tendancy to anemia
70. Freqeuntly have "nose bleeds"
71. "Ringing in ears" or noises in head
72. Tension under breast-bone, or feeling "tightness" in the chest, gets worse on exertion
73. Dizziness
74. Dry Skin
75. Burning feet
76. Blurred vision
77. Itching skin and feet
78. Excessive falling hair
79. Frequent skin rashes
80. Bitter or metallic tast in mouth in the mornings
81. Bowel movements painful or difficult
82. Feelings of worry, dread, or insecurity
83. Feeling queasy; headache over eyes
84. Greasy foods upset
85. Stools light-colored
86. Skin peels on foot soles
87. Pain between shoulder blades
88. Using laxatives
89. Stools alternate from soft to watery
90. History of gallbladder attacks or gall stones
91. Sneezing attacks
92. Dreaming, nightmare-type bad dreams
93. Bad breath (halitosis)
94. Milk products cause distress
95. Sensitive to hot weather
96. Burning or itching anus
97. Crave sweets
98. Loss of taste for meat
99. Lower bowel gas several hours after eating
100. Burning stomach sensations, eating relieves
101. Coated tongue
102. Large amounts of foul smelling gas
103. Indigestion 1/2 - 1 hour after eating; may be up to 3-4 hours
104. Mucus colitis or "irritable bowel"
105. Gas shortly after eating
106. Stomach "bloating" after eating
107. Insomnia
108. Nervousness
109. Can't gain weight
110. Intolerance to heat
111. Highly emotional
112. Flush easily
113. Night sweats
114. Skin is thin and moist
115. Inward trembling
116. Heart palpitates
117. Increased appetite without weight gain
118. Pulse races when resting
119. Eyelids and face twitch
120. Irritable and restless
121. Can't work under pressure
122. Noticable weight gain
123. Decrease in appitite
124. Easily fatigued
125. Ringing in ears
126. Sleeping during the day
127. Sensitive to cold
128. Dry or scaly skin
129. Constipation
130. Mental sliggishness
131. Hair coarse, falls out
132. Headaches, upon arising wear off during the day
133. Slow pulse, below 65
134. Frequent urination
135. Impaired hearing
136. Reduced initiative
137. Failing memory
138. Low blood pressure
139. Increased sex drive
140. Headaches, "splitting or rendering" type
141. Decreased sugar tolerance
142. Abnormal thirst
143. Bloating of the abdomen
144. Weight gain around hips or waist
145. Sex drive redued or lacking
146. Tendency toward ulcers and/or colitis
147. Increased sugar tolerance
148. (FEMALE) Menstrual disorders
149. (YOUNG GIRLS) Lack of mentrual function
150. Dizziness
151. Headaches
152. Hot flashes
153. Increased blood pressure
154. (FEMALE) Hair growth on face or body
155. Sugar in urine (not diabetes)
156. (FEMALE) Masculine tendancies
157. Weakness and/or dizziness
158. Chronic fatigue
159. Low blood pressure
160. Nails weak and/or ridged
161. Tendency toward hives
162. Arthritic tendancies
163. Perspiration increase
164. Bowel disorders
165. Poor circulation
166. Swollen ankles
167. Crave salt
168. Brown spots or bronzing of skin
169. Allergies - tendancy to asthma
170. Weakness after colds or influenza
171. Muscular and nervous exhaustion
172. Respiratory disorders
173. Apprehension
174. Irritability
175. Morbid fears
176. Never seems to get well
177. Forgetfulness
178. Indigestion
179. Poor appetite
180. Craving for sweets
181. Muscular soreness
182. Depression; feelings of dread
183. Noise sensitivity
184. Acoustic hallucinations
185. Tendancy to cry without reason
186. Hair is coarse and/or thinning
187. Weakness
188. Fatigue
189. Skin sensitve to touch
190. Tendency toward hives
191. Nervousness
192. Headache
193. Insomnia
194. Anxiety
195. Anorexia
196. Inability to concentrate; confusion
197. Frequent stuffy nose; sinus infections
198. Allergy to some foods
199. Loose joints
200. (FEMALE) Very easily fatigued
201. (FEMALE) Premenstrual tension
202. (FEMALE) Painful menses
203. (FEMALE) Depressed feelings before menstruation
204. (FEMALE) Excessive and prolonged mensturation
205. (FEMALE) Painful breasts
206. (FEMALE) Menstruate hot flashes
207. (FEMALE) Vaginal discharge
208. (FEMALE) Hysterectomy/ovaries removed
209. (FEMALE) Menopausal hot flashes
210. (FEMALE) Menses scanty or missed
211. (FEMALE) Acne, worse at menses
212. (FEMALE) Long standing depression
213. (MALE) Prostate trouble
214. (MALE) Urination difficult or dribbling
215. (MALE) Frequent night time urination
216. (MALE) Depression
217. (MALE) Pain on inside of legs or heels
218. (MALE) Feeling of incomplete bowel evacuation
219. (MALE) Lack of energy
220. (MALE) Migrating aches and pains
221. (MALE) Too easily tired
222. (MALE) Avoids activity
223. (MALE) Leg nervousness at night
224. (MALE) Dimished sex drive
List your five main physical complaints in order of importance
List any surgery's or organs removed

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