Dr. Jack Stockwell: Symptom Survey

	Step through this survey to request a custom-fit product prescription. NOTE: Do not hit the Back or Refresh buttons. If you ended your session early but are now continuing, please click here to re-enter your full name, then click the "Next" buttons until you reach the current survey page.

Note: Product information and suggested usage are for your information and education only. No medical claims are intended or implied. For specific medical advice, consult a health care professional, or contact us.

NUTRITEC SOFTWARE SYMPTOM SURVEY FORM
GROUP 1: SYMPATHETIC DOMINANCE
Proper nutrition and health is custom to each of us. Please take some time to fill out the Symptom Survey form below, which will help focus our products and recommended treatments to your specific needs.

There is a charge of $25 for non-patients.

GENERAL INFORMATION

Full Name*

Email Address*

Home Phone (include area code)
()-

Sex*
Male
Female

Height
Feet Inches

Weight
Pounds

INSTRUCTIONS: For each question, select the button that best applies to you today.
EX1 MILD Symptoms: Once or twice last 6 months
EX2 MODERATE Symptoms: Once or twice last month
EX3 SEVERE Symptoms: Chronic, once or twice last week
EX4 BLANK: Does not apply to you

GROUP 1: SYMPATHETIC DOMINANCE (20 questions)
001 Acid foods upset
002 Feel chilled often
003 "Lump" in throat
004 Dry mouth-eyes-nose
005 Pulse speeds after meals
006 Keyed up; unable to feel calm
007 Cuts heal slowly
008 Gag easily
009 Unable to relax; startles easily
010 Extremities cold and/or clammy
011 Strong light irritates
012 Urine amount reduced
013 Heart pounds after retiring
014 "Nervous" stomach
015 Appetite reduced
016 Cold sweats often
017 Body temperature rises easily
018 Skin sensitive to touch
019 Staring, blinks little
020 Frequently have a sour stomach

to GROUP 2 of 8: PARASYMPATHETIC DOMINANCE (21 questions)

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