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Standard Process

Systems Survey 2

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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 - 2

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 3

Eat when nervous
1
2
3
Excessive appetite
1
2
3
Hungry between meals
1
2
3
Irritable before meals
1
2
3
Get “shaky” if hungry
1
2
3
Fatigue, eating relieves
1
2
3
“Lightheaded” if meals delayed
1
2
3
Heart palpitates if meals missed or delayed
1
2
3
Fatigue in afternoon
1
2
3
Overeating sweets upsets
1
2
3
Awaken after few hours sleep, hard to get back to sleep
1
2
3
Crave candy or coffee in afternoon
1
2
3
Moods of “blues” or melancholy
1
2
3
Craving for sweets or snacks
1
2
3

Group 4

Hands and feet go to sleep easily, numbness
1
2
3
Sigh frequently, “air hunger”
1
2
3
Aware of “breathing heavily”
1
2
3
High-altitude discomfort
1
2
3
Open windows in closed room
1
2
3
Immune system challenges
1
2
3
Afternoon “yawner”
1
2
3
Get “drowsy” often
1
2
3
Swollen ankles worse at night
1
2
3
Muscle cramps, worse during exercise; get “charley horse”
1
2
3
Difficulty catching breath, especially during exercise
1
2
3
Tightness or pressure in chest, worse on exertion
1
2
3
Skin discolors easily after impact
1
2
3
Tendency to anemia
1
2
3
Noises in head or “ringing in ears”
1
2
3
Fatigue upon exertion
1
2
3

Group 5

Dizziness
1
2
3
Dry skin
1
2
3
Burning feet
1
2
3
Blurred vision
1
2
3
Itching skin and feet
1
2
3
Hair loss
1
2
3
Occasional skin rashes
1
2
3
Bitter, metallic taste in mouth in morning
1
2
3
Occasional constipation
1
2
3
Worrier, feels insecure
1
2
3
Nausea occasionally after eating
1
2
3
Greasy foods upset
1
2
3
Stools light-colored
1
2
3
Skin peels on foot soles
1
2
3
Discomfort between shoulder blades
1
2
3
Occasional laxative use
1
2
3
Stools alternate from soft to watery
1
2
3
Sneezing attacks
1
2
3
Dreaming, nightmare-type bad dreams
1
2
3
Bad breath (halitosis)
1
2
3
Milk products cause upset
1
2
3
Sensitive to hot weather
1
2
3
Burning or itching anus
1
2
3
Crave sweets
1
2
3

Group 6

Loss of taste for meat
1
2
3
Lower bowel gas several hours after eating
1
2
3
Burning stomach sensations, eating relieves
1
2
3
Coated tongue
1
2
3
Pass large amounts of foul-smelling gas
1
2
3
Indigestion ⅟2 -1 hour after eating; may be up to 3-4 hours after
1
2
3
Watery or loose stool
1
2
3
Gas shortly after eating
1
2
3
Stomach “bloating”
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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