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StandardProcess

Systems Survey 4

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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 - 4

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 8

Muscle weakness
1
2
3
Lack of stamina
1
2
3
Drowsiness after eating
1
2
3
Muscular soreness
1
2
3
Heart races
1
2
3
Hyperirritable
1
2
3
Feeling of a band around head
1
2
3
Melancholia (feeling of sadness)
1
2
3
Swelling of ankles
1
2
3
Change in urinary function
1
2
3
Tendency to consume sweets/carbohydrates
1
2
3
Muscle spasms
1
2
3
Blurred vision
1
2
3
Involuntary muscle action
1
2
3
Numbness
1
2
3
Night sweats
1
2
3
Rapid digestion
1
2
3
Sensitivity to noise
1
2
3
Redness of palms of hands and bottom of feet
1
2
3
Visible veins on chest and abdomen
1
2
3
Hemorrhoids
1
2
3
Apprehension (feeling that something bad is going to happen)
1
2
3
Nervousness causing loss of appetite
1
2
3
Nervousness with indigestion
1
2
3
Gastritis
1
2
3
Forgetfulness
1
2
3
Thinning hair
1
2
3

Female Only

Very easily fatigued
1
2
3
Premenstrual tension
1
2
3
Menses more painful than usual
1
2
3
Depressed feelings before menstruation
1
2
3
Painful breasts during menses
1
2
3
Menstruate too frequently
1
2
3
Hysterectomy/ovaries removed
1
2
3
Menopausal hot flashes
1
2
3
Menses scanty or missed
1
2
3
Acne, worse at menses
1
2
3

Male Only

Less involved in exercise/social activities
1
2
3
Difficult to postpone urination
1
2
3
Weak urinary stream
1
2
3
Feeling of “blues” or melancholy
1
2
3
Feeling of incomplete bowel evacuation
1
2
3
Lack of energy
1
2
3
Muscles in arms and legs seem softer/smaller
1
2
3
Tire too easily
1
2
3
Avoid activity
1
2
3
Leg nervousness at night
1
2
3
Diminished sex drive
1
2
3

Important | Please list below the five main physical complaints you have in order of their importance:

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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