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C. Norman Shealy, M.D., Ph.D.
If you have 10 or more symptoms, you need careful evaluation by a truly HOLISTIC Physician!
Name: ——————————— Date: ——————

When people-are chronically ill, they often have other symptoms. Do you have any of the following? PLEASE CHECK ONLY THOSE THAT YOU HAVE NOW OR HAVE HAD WITH YOUR CURRENT ILLNESS.

__ Depressed mood.
__ Loss of interest or pleasure in things you.used to enjoy;
__ Significant weight change/loss or gain).
__ Frequent eating between meals.
__ Insomnia.
__ Hypersomnia.
__ Sleep walking.
__ Agitation
__Sluggishness, slow to function.
__ Fatigue, low energy, feeling tired a lot the time.
__ Feelings of worthlessness or guilt.
__ Difficulty concentrating, thinking, and remembering.
__ Indecisiveness.
__ Recurrent thoughts of death or suicide.
__ Suicide attempts.
__ Nervous exhaustion.
__ Worrying excessively or being anxious.
__ -Frequent crying.
__ Being extremely shy or sensitive.
__ Lumps or swelling in your neck.
__ Blurring of vision.
__ Seeing double. –
__ Seeing colored halos around lights.
__ Pains or itching around the eyes.
__ Excess blinking or watering of the eyes.
__ Loss of vision.
__ Difficulty hearing.
__ Ear ache.
__ Running ear.
__ Buzzing or other noises in the ears.
__ Motion sickness.
__ Teeth or gum problems.
__ Sore or sensitive tongue.
__ Change in sense of taste .
__ Nose stuffed up.
__ Runny nose.
__ Sneezing spells.
__ Frequent head colds.
__ Bleeding from the nose.
__ Sore throat even without a cold.
__ Enlarged tonsils.
__ Hoarse voice even without a cold .
__ Difficulty or pain in swallowing.
__Wheezing or difficulty breathing
__ Coughing spells.
__ Coughing up a lot of phlegm.
__ Coughing up blood.
__ Chest colds more than once a month.
__ High blood pressure.
__ Low blood pressure.
__ Heart trouble .
__ Thumping or racing heart.
__ Pain or tightness in the chest.
__ Shortness of breath.
__ Heartburn.
__ Feeling bloated.
__ Excess belching.
__ Discomfort in the pit of your stomach.
__ Nausea.
__ Vomiting blood.
__ Peptic ulcer.
__ Change in appetite.
__ Digestive problems.
__ Excess hunger.
__ Getting up frequently at night to urinate.
__ Urinating more than 5-6 times a day.
__ Unable to control your urine.
__ Burning or pains when you urinate.
__ Black, brown, or bloody urine.
__ Difficulty starting yoururine.
__ Constant urge to urinate.
__ Constipation
__ Diarrhea.
__ Black or bloody bowel movement.
__ Grey bowel movement.
__ Pain when you move your bowels.
__ Bleeding from your rectum.
__ Stomach pains which double you up.
__ Frequent stomach trouble.
__ Intestinal worms.
__ Hemorrhoids.
__ Yellow jaundice.
__ Biting your nails.
__ Stuttering or stammering.
__ Any kind of problem with your genital or sexual organs.
__ Sexual problems.
__ Hernia or rupture.
__ Kidney or bladder disease.
__ Stiff or painful muscles or joints.
__Swelling joints.
__ Pain in your back or shoulders.
__ Painful feet.
__ Swelling in your armpits or groin.
__ Trouble with swollen feet or ankles.
__ Cramps in your legs at night or with walking.
__ Itching or burning skin.
__ Excess bleeding from a small cut.
__ Easy burning skin.
__ Dizziness or light headedness.
__ Feeling faint or fainting.
__ Numbness in any part of your body.
__ Cold hands or feet even in hot weather.
__ Paralysis.
__ Blacking out.
__ Fits, convulsions, or epilepsy.
__ Change in your handwriting.
__ Tendency to shake or tremble.
__ Tendency to be too hot or too cold.
__  Sweating more than usual.
__ Hot flashes.
__ Being short of breath with minimal effort.
__ Failure-to .get adequate exercise.
__ Being overweight.
__ Being underweight.
__ Having lost more that half your teeth.
__ Bleeding gums.
__ Badly coated tongue.
__ A lot of small accidents or injuries.
__ Varicose veins.
__ Headaches.
__ Other aches or pains.
__ Feeling pessimistic or hopeless.
__ Have had any kind of surgery within the past year.
__ Being upset easily by criticism.
__ Having little annoyances get on your nerves and make you angry.
__ Getting angry easily.
__ Getting nervous around strangers.
__ Feeling lonely.
__ Having difficulty relaxing.
__ Being troubled by frightening dreams or thoughts.
__ Being disturbed by work or family problems.
__ Wishing that you could get psychological or psychiatric help.
__ Being tense or jittery.
__ Being easily upset.
__ Being in low spirits.
__ Being in very low spirits.
__ Believing that your life is out of your hands and controlled by external forces.
__ Feeling that life is empty, filled with despair,
__ Having no goals or aims at all.
__ Having failed to make progress towards your life goals.
__ Feeling that you are completely bound by factors outside yourself.
__ Feeling sad, blue. Or down in the dumps.
__ Feeling slowed down or restless and.unable to sit still.

__ Being confined to bed by illness.

For men only:
__ Having urine stream that is very weak or very slow.
__ Having prostate trouble.
__ Having unusual burning or discharge from your penis.
__ Having swelling or lumps in your testicles.
__ Having your testicles painful.

__ Having trouble getting erections (getting hard).

For women only:
__ Having trouble with your menstrual period.
__ Bleeding between your periods.
__ Having heavy bleeding with your periods.
__ Getting bloated or irritable before your periods.
__ Taking birth control pills (in the last year).
__ Having lumps in your breasts.
__ Having excess discharge from your vagina.
__ Feeling weak: or sick with your periods.
__ Having to lie down when your periods start.
__ Feeling tense and jumpy with your periods.
__ Having constant hot flashes and sweats.

__ Have had a hysterectomy or on hormonal replacement.

Copyright C. Norman Shealy, M.D., Ph.D., Springfield, Missouri,2016
sHEALyWellness | | | 5607 S. 222nd Rd.
Fair Grove, MO 65648
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