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Systems Survey


Select the number that applies to you. If a symptom does not apply, select N/A for that symptom. The Next button to proceed to the following section will appear when each symptom has been addressed.

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

Group 1

Acid foods upset

Get chilled often

"Lump" in throat

Dry mouth, eyes, nose

Pulse speeds after meal

Keyed up, fail to calm

Gag occasionally

Unable to relax, startle easily

Extremities cold, clammy

Strong light irritates

Occasionally weak urine flow

Heart pounds after retiring

"Nervous" stomach

Appetite reduced occasionally

Cold sweats often

Get heated easily

Nerve discomfort

Staring, blink little

Sour stomach frequent

*These statements have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure, or prevent any disease.