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Client Information: Continued Page (6) 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 SEVEN

(A)
(C)
(E)
1. Pulse fast at rest
19. Low blood pressure
32. Hot flashes
2. Nervousness
20. Failing memory
33. Headaches
3. Can’t gain weight
21. Increased sex desire
34. Dizziness
4. Intolerance to heat
22. Headaches, “splitting or rending type”
35. Increased blood pressure
5. Highly emotional
23. Decreased sugar tolerance
36. Sugar in urine
(not diabetes)
6. Rush easily
37. Masculine tendenosis (female)
7. Night sweats
8. Inward trembling
(F)
9. Heart palpitates
38. Low blood pressure
10. Insomnia
39. Chronic fatigue
(B)
(D)
 40. Weakness, dizziness
11. Impaired hearing
24. Bloating of intestines
41. Tendency to hives
12. Decrease in appetite
25. Abnormal thirst
42. Arthritic tendencies
13. Ringing in ears
26. Weight gain around hips or waist
43. Perspiration increase
14. Constipation
27. Sex desire reduced or lacking
44. Crave salt
15. Mental sluggishness
28. Tendency to ulcers or colitis
45. Brown spots or bronzing of skin
16. Headaches upon arising wear off during day
29. Increased sugar tolerance
46. Allergies - tendency
to asthma
17. Slow Pulse, below 65
30. Women: menstrual disorders
47. Exhaustion - muscular and nervousness
18. Increase in weight
31. Young girls:lack of menstrual function
48. Respiratory disorder