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StandardProcess

Systems Survey 3

AlineaHealth

​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 - 3

Restricted to Professional Use

Group 7A

No Symptom - Leave Blank

1 - MILD symptom (occurs rarely)

2 - MODERATE symptom (occurs several times a month)

3 - SEVERE symptom (occurs almost constantly)

Difficulty sleeping
1
2
3
On edge
1
2
3
Can’t gain weight
1
2
3
Intolerance to heat
1
2
3
Highly emotional
1
2
3
Flush easily
1
2
3
Night sweats
1
2
3
Thin, moist skin
1
2
3
Inward trembling
1
2
3
Heart races
1
2
3
Increased appetite without weight gain
1
2
3
Pulse fast at rest
1
2
3
Eyelids and face twitch
1
2
3
Irritable and restless
1
2
3
Can’t work under pressure
1
2
3

Group 7B

Increase in weight
1
2
3
Decrease in appetite
1
2
3
Fatigue easily
1
2
3
Ringing in ears
1
2
3
Sleepy during day
1
2
3
Sensitive to cold
1
2
3
Dry or scaly skin
1
2
3
Temporary constipation
1
2
3
Mental sluggishness
1
2
3
Hair coarse, falls out
1
2
3
Tension in head upon arising wears off during day
1
2
3
Slow pulse below 65
1
2
3
Changing urinary function
1
2
3
Sounds appear diminished
1
2
3
Reduced initiative
1
2
3

Group 7C

Failing memory with age
1
2
3
Increased sex drive
1
2
3
Episodes of tension in head
1
2
3
Decreased sugar tolerance
1
2
3

Group 7D

Abnormal thirst
1
2
3
Bloating of abdomen
1
2
3
Weight gain around hips or waist
1
2
3
Sex drive reduced or lacking
1
2
3
Tendency for stomach issues
1
2
3
Immune system challenges
1
2
3
Menstrual disorders
1
2
3

Group 7E

Dizziness
1
2
3
Headaches
1
2
3
Hot flashes
1
2
3
Hair growth on face or body (female)
1
2
3
Sugar in urine (not diabetes)
1
2
3
Masculine tendencies (female)
1
2
3

Group 7F

Weakness, dizziness
1
2
3
Tired throughout day
1
2
3
Nails weak, ridged
1
2
3
Sensitive skin
1
2
3
Stiff joints
1
2
3
Perspiration increase
1
2
3
Bowel discomfort
1
2
3
Poor circulation
1
2
3
Swollen ankles
1
2
3
Crave salt
1
2
3
Areas of skin darkening
1
2
3
Upper respiratory sensitivity
1
2
3
Tiredness
1
2
3
Breathing 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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