Glandular/Endocrine System Intake Form


If any of the following symptoms or activities have occurred within the past three months (unless otherwise specified), please indicate by checking: 1 for mild or rarely occurring, 2 for moderate or regularly occurring, 3 for severe or often occurring, or leave blank if the symptom/statement does not apply.

Distinct, lethargic tiredness or sluggishness
Cold hands or feet
Mercury amalgams (fillings)
Gain weight easily, fail to lose on diets
Constipation, less than one bowel movement a day
Low energy in the morning
Low pulse rate
Low body temperature, especially at bed rest
Hair dry, brittle, dull, lifeless
Flaky, dry, rough skin
Feel stiff after sitting still for some time
Mood swings
Usually square and wide fingernails
High cholesterol
Diminished sex drive
Infertility or impotence
Headaches affecting one side of the head
Female: Loss of menstrual function
Overweight from waist down
Overweight from waist up
Excessive urination
Pain in little finger of left hand
Swelling in ankles, fingers or feet
Pain in left side of upper neck
Losing weight without trying
Heart races while at rest
Feel warm/flushed at room temperature
Hands shake or tremble
Protruding tongue
Heart palpitations
Nervous behavior, hyperactivity
Increased appetite
Frequent bowel movements, diarrhea
Excessive sweating without exercising
Stress or emotional upsets cause exhaustion
Blood pressure decreases when going from a lying position to a standing position
Perspire excessively
Neck and/or shoulder tension
Frequent headaches
Bow lines (depressed furrows) on fingernails
Occasional cold sweats
Tightness or lump in throat, especially when emotionally disturbed
High or low blood pressure
Rapid pulse
Short temper
Puffy face
Word Verification: