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Standard Process

Systems Survey 1

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​Please take your time and fully complete all information and submit each form. 

 

This will greatly faciliate information exchange and preparation for your visit :)

 

If you have any questions, feel free to call or message us at 301-582-3009, or email office@alineanaturalhealth.com and we will get back to you asap for assistance.

You can navigate to specific forms using the buttons below.  You may come back later to complete subsequent forms if you'd like.  Please fully complete and submit each separate form before leaving though, to ensure that the info is saved. If you want to complete them all now, simply click the "Next" buttons at the bottom of each form when finished.

***NOTE***: For These Systems Survey Forms... when answering questions...if you do not have the symptom listed, please leave the response blank.  Only select 1, 2 or 3 if you are experiencing the symptom.

Standard Process

SYSTEMS SURVEY FORM - 1

Restricted to Professional Use

No Symptom - Leave Blank

1 - MILD symptom (occurs rarely)

2 - MODERATE symptom (occurs several times a month)

3 - SEVERE symptom (occurs almost constantly)

Group 1

Acid foods upset
1
2
3
Get chilled often
1
2
3
“Lump” in throat
1
2
3
Dry mouth, eyes, nose
1
2
3
Pulse speeds after meal
1
2
3
Keyed up, fail to calm
1
2
3
Gag occasionally
1
2
3
Unable to relax, startle easily
1
2
3
Extremities cold, clammy
1
2
3
Strong light irritates
1
2
3
Occasionally weak urine flow
1
2
3
Heart pounds after retiring
1
2
3
“Nervous” stomach
1
2
3
Appetite reduced occasionally
1
2
3
Cold sweats often
1
2
3
Get heated easily
1
2
3
Nerve discomfort
1
2
3
Staring, blink little
1
2
3
Sour stomach frequent
1
2
3

Group 2

Joint stiffness after arising
1
2
3
Muscle, leg, toe cramps at night
1
2
3
“Butterfly” stomach, cramps
1
2
3
Eyes or nose watery
1
2
3
Eyes blink often
1
2
3
Eyelids swollen, puffy
1
2
3
Indigestion soon after meals
1
2
3
Always seem hungry, feel “lightheaded” often
1
2
3
Digestion rapid
1
2
3
Vomit occasionally
1
2
3
Hoarseness frequent
1
2
3
Uneven breathing
1
2
3
Pulse slow
1
2
3
Gagging reflex slow
1
2
3
Difficulty swallowing
1
2
3
Temporary constipation or diarrhea
1
2
3
“Slow starter”
1
2
3
Get “chilled”
1
2
3
Perspire easily
1
2
3
Sensitive to cold
1
2
3
Upper respiratory challenges
1
2
3

Restrictions on Use:

The systems survey is to be used only by trained health care professionals. If you are a patient, you should not use the systems survey. If you are not a trained health care practitioner, you should not use the systems survey. Health care practitioners should only use the systems survey to provide services that are within the scope of their license or professional training. The systems survey is intended to be used as a helpful tool for health care practitioners in collecting information concerning the health and wellness of patients.

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