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Client Information: Continued Page (4) of 9

Name Date

INSTRUCTIONS
Number the weaknesses which apply to you.  If it doesn't apply, leave it blank.

Use: (1) - for Mild symptoms / (2) • for Moderate symptoms / (3) - for Severe Symptoms.

GROUP ONE

1. “Nervous” stomach
5. Mentally alert, quick 9. Cold sweats often
2. Dry Mouth-eyes-nose 6. Extremities cold, clammy 10. Fever easily raised
3. Pulse speeds after meal 7. Heart pounds after retiring 11. Neuralgia-like pains
4. Keyed up - fail to calm 8. Acid foods upset 12. Are your weaknesses made worse by emotional stress?

GROUP TWO

1. Perspire easily
5. Digestion rapid 9. Joint stiffness after rising
2. Muscle-leg-toe cramps at night 6. Vomiting frequent 10. Circulation poor, sensitive to cold
3. Eyelids swollen, puffy 7. Difficulty swallowing 11. Subject to colds,asthma, bronchitis
4. Indigestion soon after meals 8. Constipation, Diarrhea alternating 12. Are your weaknesses made worse by physical stress?

GROUP THREE

1. Afternoon headaches
4. Awaken after few hours’ sleep hard to get back to sleep 7. Crave candy or coffee
2. Get “shaky” if hungry in afternoons 5. Heart palpitates if meals missed or delayed 8. Abnormal craving for sweets or snacks
3. Faintness if meals delayed 6. Eat when nervous