NUTRITEC SOFTWARE SYMPTOM SURVEY FORM

GROUP 1: SYMPATHETIC DOMINANCE
Proper nutrition and health is custom to each of us. Please take some time to fill out the Symptom Survey form below, which will help focus our products and recommended treatments to your specific needs.

There is a charge of $25 for non-patients.

GENERAL INFORMATION

Full Name*


Email Address*


Home Phone (include area code)
( ) -

Sex*
Male
Female

Height
Feet   Inches

Weight
Pounds

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INSTRUCTIONS: For each question, select the button that best applies to you today.
EX1 = MILD Symptoms: Once or twice last 6 months
EX2 = MODERATE Symptoms: Once or twice last month
EX3 = SEVERE Symptoms: Chronic, once or twice last week
EX4 = BLANK: Does not apply to you

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GROUP 1: SYMPATHETIC DOMINANCE (20 questions)
001 Acid foods upset
002 Feel chilled often
003 “Lump” in throat
004 Dry mouth-eyes-nose
005 Pulse speeds after meals
006 Keyed up; unable to feel calm
007 Cuts heal slowly
008 Gag easily
009 Unable to relax; startles easily
010 Extremities cold and/or clammy
011 Strong light irritates
012 Urine amount reduced
013 Heart pounds after retiring
014 “Nervous” stomach
015 Appetite reduced
016 Cold sweats often
017 Body temperature rises easily
018 Skin sensitive to touch
019 Staring, blinks little
020 Frequently have a sour stomach

to complete GROUP 2 of 8: PARASYMPATHETIC DOMINANCE (21 Questions)