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Instructions:
Number the lines that apply to you with either a 1,2, or 3.
(1) For MILD Symptoms (Occur once or twice a year)
(2) For MODERATE Symptoms (Occur several times a year)
(3) For SEVERE Symptoms (You are aware of it almost constantly)
GROUP 2
21 Joint Stiffness after rising 22 Muscle -Leg- Toe Cramps at night 23 "Butterfly" stomach, cramps 24 Eyes or nose watery 25 Eyes blink often 26 Eyelids swollen puffy 27 Indigestion soon after meals 28 Always seem hungry; feel light headed often 29 Digestion rapid 30 Vomiting frequent 31 Hoarseness frequent 32 Breathing irregular 33 Pulse slow; feels irregular 34 Gagging reflex slow 35 Difficulty swallowing 36 Constipation, Diarrhea alternating 37 "Slow starter" 38 Get "chilled" frequently 39 Perspire easily 40 Circulation cold
GROUP 3
41 Subject to colds, asthma, bronchitis 42 Eat when nervous 43 Excessive appetite 44 Hungry between meals 45 Irritable before meals 46 Get "shaky" if hungry 47 Fatigue, eating relieves 48 "Lightheaded if meals delayed 49 Heart palpitates if meals missed or delayed 50 Afternoon headaches 51 Overeating sweets upsets 52 Awaken after few hours sleep, hard to get back to sleep 53 Crave candy or coffee in the afternoons 54 Moods of depression, blues or Melancholy 55 Abnormal craving for sweets or snacks GROUP 4 56 Hands and feet go to sleep easily, numbness 57 Sigh frequently "air hunger" 58 Aware of breathing heavily 59 High altitude discomfort 60 Open windows in closed rooms 61 Susceptible for colds and fevers 62 Afternoon yawner 63 Get drowsy often 64 Swollen ankles worse at night 65 Muscle cramps. Worse during exercise, get "charlie horses" 66 Shortness of breath on inspiration 67 Dull pain in chest, radiating into left arm worse on exertion 68
