Systems Survey Form

Restricted to Professional Use

Circle/select the corresponding number:

1 MILD symptom (occurs rarely) 2 MODERATE symptom (occurs several times a month) 3 SEVERE symptom (occurs almost constantly)

Name(Required)

Age

Health Care Professional

Date

Group 1

1. Acid foods upset

1

2

3

2. Get chilled often

1

2

3

3. “Lump” in throat

1

2

3

4. Dry mouth, eyes, nose

1

2

3

5. Pulse speeds after meal

1

2

3

6. Keyed up, fail to calm

1

2

3

7. Gag occasionally

1

2

3

8. Unable to relax, startle easily

1

2

3

9. Extremities cold, clammy

1

2

3

10. Strong light irritates

1

2

3

11. Occasionally weak urine flow

1

2

3

12. Heart pounds after retiring

1

2

3

13. “Nervous” stomach

1

2

3

14. Appetite reduced occasionally

1

2

3

15. Cold sweats often

1

2

3

16. Get heated easily

1

2

3

17. Nerve discomfort

1

2

3

18. Staring, blink little

1

2

3

19. Sour stomach frequent

1

2

3

Group 1 Total

Main Physical Complaints

Please list below the five main physical complaints you have in order of their importance.

1. Physical Complaint

2. Physical Complaint

3. Physical Complaint

4. Physical Complaint

5. Physical Complaint

To Be Completed by Health Care Professional

Hydrochloric Acid Point

Enzyme Point

Murphy’s Sign

Large Intestine – Ascending

Large Intestine – Transverse

Large Intestine – Descending

Pupil Dilation Exam

Pass

Fail

Postural Hypotension – Supine

Postural Hypotension – Standing

Zinc Taste Test

Pass

Fail

Cuff Test

Pass

Fail

Cuff Pressure

pH of Saliva

Pulse

Barnes Thyroid Test

The test is conducted by the patient in the morning before leaving bed, with the temperature being taken for 10 minutes. The test is invalidated if the patient expends any energy prior to taking the test such as getting up for any reason, shaking down the thermometer, etc. It is important that the test be conducted for exactly 10 minutes, making the prior positioning of both the thermometer and a clock important.

Barnes Thyroid Test – Day 1

Barnes Thyroid Test – Day 2

Barnes Thyroid Test – Day 3

Barnes Thyroid Test – Day 4

Barnes Thyroid Test – Day 5

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.

Dr. Laurie Beagle Chiropractor - Chiropractor in Coopersburg, PA

Symptom Survey

Systems Survey Form

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7A

Group 7B

Group 7C

Group 7D

Group 7E

Group 7F

Group 8

Female Only

Male Only

Main Physical Complaints

To Be Completed by Health Care Professional

Barnes Thyroid Test

Restrictions on Use

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Symptom Survey

Systems Survey Form

Group 1

Group 2

Group 3

Group 4

Group 5

Group 6

Group 7A

Group 7B

Group 7C

Group 7D

Group 7E

Group 7F

Group 8

Female Only

Male Only

Main Physical Complaints

To Be Completed by Health Care Professional

Barnes Thyroid Test

Restrictions on Use

Visit Us

This site uses tracking technologies

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