Lionville Natural Pharmacy Consultation Instructions
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BEFORE ATTENDING CONSULTATION YOU MUST:
THANK YOU FOR YOUR COOPERATION Please note: if you are interested in a consultation for human hormone replacement therapy, you must fill out both this form and the Human Hormone Replacement Confidential Symptom Survey.
PHONE: 610-363-7474 
FAX: 610-363-5707
Lionville Natural Pharmacy & Health Food Store Symptom Survey
Name: __________________________________________
Date of Birth: ___________________________ Height: _________ Referred by: _______________________________________________________
Gender: _____________
Weight: _________
INSTRUCTIONS: Completely black out one of the three circles: 1-mild, 2-moderate, 3-severe
List below your five main physical complaints in order of importance:
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
Medical History
1. Please list all current medications and supplements:
2. List any drug, supplement or food allergies:
3. List current health conditions or diagnoses:
4. List current health care practitioners and specialty:
5. Please answer Yes or No to the following questions:
A Body Scan Bioimpedance Analyzer (BIA) test is available if you are interested. This test will measure Lean Body Mass (LBM), Fat Mass, Body Mass Index (BMI), Intracellular water content, Extracellular water content, hydration status, cardiovascular risk, cellular membrane health, toxicity and longevity status, and basal metabolic rate. This test will be given at the time of the consultation and repeated in approximately six weeks for comparison.
The cost of the BIA scan is $10.00 for two scans. You will be required to remove right shoe and sock/stocking during the scan, then asked to lie down. The scan takes about five minutes, and there is no discomfort during the procedure. The BIA scan is a highly recommended diagnostic tool.
MILD symptoms (once or twice in the last 6 months)
MODERATE symptoms (once or twice last month)
SEVERE symptoms (chronic, once or twice last week)
Leave circles BLANK if they do not apply to you!
GROUP 1: SYMPATHETIC DOMINANCE 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 a sour stomach GROUP 2: PARASYMPATHETIC DOMINANCE 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 digests rapidly 30 Vomit frequently 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 GROUP 3: SUGAR HANDLING 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 coffee in afternoons 54 Moods of depression, "blues," or melancholy 55 Abnormal craving for sweets or snacks GROUP 4: CARDIOVASCULAR 56 Hands and feet go to sleep easily, numbness 57 Sigh 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, worse on exertion 68 Bruise easily, black/blue spots on arms or legs 69 Tendency to anemia 70 Frequently have nose bleeds 71 Ringing in ears or noises in head 72 Tension under the breast-bone, or feeling of tightness in the chest, gets worse on exertion GROUP 5: LIVER/BILIARY 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 taste 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 GROUP 6: DIGESTION 98 Loss of taste for meat 99 Lower bowel gas several hours after eating 100 Burning stomach sensations, eating relieves 101 Coated tongue 102 Pass 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 GROUP 7A: HYPERTHYROID 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 GROUP 7B: HYPOTHYROID 122 Noticable weight gain 123 Decrease in appetite 124 Easily fatigued 125 Ringing in ears 126 Sleepy during day 127 Sensitive to cold 128 Dry or scaly skin 129 Constipation 130 Mental sluggishness 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 GROUP 7C: HYPERPITUITARY 137 Failing memory 138 Low blood pressure 139 Increased sex drive 140 Headaches, "splitting or rendering" type 141 Decreased sugar tolerance GROUP 7D: HYPOPITUITARY 142 Abnormal thirst 143 Bloating of the abdomen 144 Weight gain around hips or waist 145 Sex drive reduced or lacking 146 Tendency toward ulcers and/or colitis 147 Increased sugar tolerance 148 (FEMALE) Menstrual disorders 149 (YOUNG GIRLS) Lack of menstrual function GROUP 7E: HYPERADRENAL 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 tendencies GROUP 7F: HYPOADRENAL 157 Weakness and/or dizziness 158 Chronic fatigue 159 Low blood pressure 160 Nails weak and/or ridged 161 Tendency toward hives 162 Arthritic tendencies 163 Perspiration increase 164 Bowel disorders 165 Poor circulation 166 Swollen ankles 167 Crave salt 168 Brown spots or bronzing of skin 169 Allergies - tendency to asthma 170 Weakness after colds or influenza 171 Muscular and nervous exhaustion 172 Respiratory disorders GROUP 8: FOUNDATIONAL ISSUES 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 Tendency to cry without reason 186 Hair is coarse and/or thinning 187 Weakness 188 Fatigue 189 Skin sensitive 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 FEMALE ONLY 200 Very easily fatigued 201 Premenstrual tension 202 Painful menses 203 Depressed feelings before menstruation 204 Excessive and prolonged menstruation 205 Painful breasts 206 Menstruate too frequently 207 Vaginal discharge 208 Hysterectomy/ovaries removed 209 Menopausal hot flashes 210 Menses scanty or missed 211 Acnes, worse at menses 212 Long standing depression MALE ONLY 213 Prostate trouble 214 Urination difficult or dribbling 215 Frequent night time urination 216 Depression 217 Pain on inside of legs or heels 218 Feeling of incomplete bowel evacuation 219 Lack of energy 220 Migrating aches and pains 221 Too easily tired 222 Avoids activity 223 Leg nervousness at night 224 Diminished sex drive
IMPORTANT
Notes:
Are you a smoker? ______
Use artificial sweeteners? ______ Do you use alcohol? ______
More than two drinks daily? ______ Have dental amalgam(s)? ______
Had root canal(s)? ______ Tubal ligation or vasectomy? ______
Surgery? ______
Radiation? ______
Chemotherapy? ______
Chelation? ______ Home water chlorinated? ______
Fluoride use? ______
Chemical pesticides use on lawn or garden? ______ Tested for Lyme disease? ______
Flu shots? ______
