Symptom Survey

235 South 400 East, Bountiful, Utah, 84010

(801) 298-1812

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Symptom Survey

Nutritec Software Symptom Survey Form
Full Name*
First Name Last Name
Date of Birth*
MM slash DD slash YYYY
Today's Date
MM slash DD slash YYYY
Height
Weight
Blood Pressure When You Are:
Sitting
Laying
Standing
Pulse When You Are:
Sitting
Standing
pH Indicators
AM Saliva
AM Urine
PM Saliva
PM Urine
Survey
Mild symptoms - Once or twice in the last 6 months
Moderate symptoms - Once or twice in the last month
Severe symptoms - Chronic, once, twice, or more in the last week

Leave BLANK if they do not apply to you!

Group 1:
1. Acid foods upset
- Mild
- Moderate
- Severe
2. Feel chilled often
- Mild
- Moderate
- Severe
3. "Lump" in throat
- Mild
- Moderate
- Severe
4. Dry mouth-eyes-nose
- Mild
- Moderate
- Severe
5. Pulse speeds after meals
- Mild
- Moderate
- Severe
6. Keyed up; unable to feel calm
- Mild
- Moderate
- Severe
7. Cuts heal slowly
- Mild
- Moderate
- Severe
8. Gag easily
- Mild
- Moderate
- Severe
9. Unable to relax; startles easily
- Mild
- Moderate
- Severe
10. Extremities cold and/or clammy
- Mild
- Moderate
- Severe
11. Strong light irritates
- Mild
- Moderate
- Severe
12. Urine amount reduced
- Mild
- Moderate
- Severe
13. Heart pounds after retiring
- Mild
- Moderate
- Severe
14. "Nervous" stomach
- Mild
- Moderate
- Severe
15. Appetite reduced
- Mild
- Moderate
- Severe
16. Cold sweats often
- Mild
- Moderate
- Severe
17. Body temperature rises easily
- Mild
- Moderate
- Severe
18. Skin sensitive to touch
- Mild
- Moderate
- Severe
19. Staring, blinks little
- Mild
- Moderate
- Severe
20. Frequently has a sour stomach
- Mild
- Moderate
- Severe
Group 2:
1. Joint stiffness after rising
- Mild
- Moderate
- Severe
2. Muscle-leg-toe cramps at night
- Mild
- Moderate
- Severe
3. "Butterfly" stomach, cramps
- Mild
- Moderate
- Severe
4. Eyes or nose watery
- Mild
- Moderate
- Severe
5. Eyes blink often
- Mild
- Moderate
- Severe
6. Eyelids swollen or puffy
- Mild
- Moderate
- Severe
7. Indigestion soon after meals
- Mild
- Moderate
- Severe
8. Always seems hungry; "lightheaded" often
- Mild
- Moderate
- Severe
9. Food digests rapidly
- Mild
- Moderate
- Severe
10. Vomit frequently
- Mild
- Moderate
- Severe
11. Frequently hoarse
- Mild
- Moderate
- Severe
12. Irregular breathing
- Mild
- Moderate
- Severe
13. Pulse slow or feels "irregular"
- Mild
- Moderate
- Severe
14. Slow gag reflex
- Mild
- Moderate
- Severe
15. Difficulty swallowing
- Mild
- Moderate
- Severe
16. Alternating constipation and diarrhea
- Mild
- Moderate
- Severe
17. "Slow starter"
- Mild
- Moderate
- Severe
18. Not easily chilled
- Mild
- Moderate
- Severe
19. Perspire easily
- Mild
- Moderate
- Severe
20. Poor circulation or sensitive to cold
- Mild
- Moderate
- Severe
21. Subject to colds, asthma, bronchitis
- Mild
- Moderate
- Severe
Group 3:
1. Eat when nervous
- Mild
- Moderate
- Severe
2. Excessive appetite
- Mild
- Moderate
- Severe
3. Hungry between meals
- Mild
- Moderate
- Severe
4. Irritable before meals
- Mild
- Moderate
- Severe
5. Get "shaky" if hungry
- Mild
- Moderate
- Severe
6. Feeling fatigued, eating relieves
- Mild
- Moderate
- Severe
7. "Lightheaded" if meals delayed
- Mild
- Moderate
- Severe
8. Heart palpitates if meals missed or delayed
- Mild
- Moderate
- Severe
9. Afternoon headaches
- Mild
- Moderate
- Severe
10. Upset feeling from excessive eating of sweets
- Mild
- Moderate
- Severe
11. Awaken after few hours sleep hard to get back to sleep
- Mild
- Moderate
- Severe
12. Crave candy or coffee in afternoons
- Mild
- Moderate
- Severe
13. Moods of depression "blues" or melancholy
- Mild
- Moderate
- Severe
14. Abnormal craving for sweets or snacks
- Mild
- Moderate
- Severe
Group 4:
1. Hands and feet go to sleep easily, numbness
- Mild
- Moderate
- Severe
2. Sigh frequently, "air hunger"
- Mild
- Moderate
- Severe
3. Aware of "breathing heavily"
- Mild
- Moderate
- Severe
4. Discomfort at high altitude
- Mild
- Moderate
- Severe
5. Opens windows in closed room
- Mild
- Moderate
- Severe
6. Susceptible to colds and fevers
- Mild
- Moderate
- Severe
7. Afternoon yawner
- Mild
- Moderate
- Severe
8. Get "drowsy" often
- Mild
- Moderate
- Severe
9. Swollen ankles worse at night
- Mild
- Moderate
- Severe
10. Muscle cramps, worse during exercise; "charley-horses"
- Mild
- Moderate
- Severe
11. Shortness of breath on exertion
- Mild
- Moderate
- Severe
12. Dull pain in chest or radiating into left arm, worse on exertion
- Mild
- Moderate
- Severe
13. Bruise easily, "black/blue" spots on arms or legs
- Mild
- Moderate
- Severe
14. Tendency to anemia
- Mild
- Moderate
- Severe
15. Frequently have "nose bleeds"
- Mild
- Moderate
- Severe
16. "Ringing in ears" or noises in head
- Mild
- Moderate
- Severe
17. Tension under the breast-bone, or feeling of "tightness" in the chest, gets worse on exertion
- Mild
- Moderate
- Severe
18. Dizziness
- Mild
- Moderate
- Severe
Group 5:
1. Dry skin
- Mild
- Moderate
- Severe
2. Burning feet
- Mild
- Moderate
- Severe
3. Blurred vision
- Mild
- Moderate
- Severe
4. Itching skin and feet
- Mild
- Moderate
- Severe
5. Excessive falling hair
- Mild
- Moderate
- Severe
6. Frequent skin rashes
- Mild
- Moderate
- Severe
7. Bitter or metallic taste in mouth in the mornings
- Mild
- Moderate
- Severe
8. Bowel movements painful or difficult
- Mild
- Moderate
- Severe
9. Feelings of worry, dread, or insecurity
- Mild
- Moderate
- Severe
10. Feeling queasy; headache over eyes
- Mild
- Moderate
- Severe
11. Greasy foods upsets
- Mild
- Moderate
- Severe
12. Stools light-colored
- Mild
- Moderate
- Severe
13. Skin peels on foot soles
- Mild
- Moderate
- Severe
14. Pain between shoulder blades
- Mild
- Moderate
- Severe
15. Using laxatives
- Mild
- Moderate
- Severe
16. Stools alternate from soft to watery
- Mild
- Moderate
- Severe
17. History of gallbladder attacks or gallstones
- Mild
- Moderate
- Severe
18. Sneezing attacks
- Mild
- Moderate
- Severe
19. Dreaming, nightmares/bad dreams
- Mild
- Moderate
- Severe
20. Bad breath (halitosis)
- Mild
- Moderate
- Severe
21. Milk products cause distress
- Mild
- Moderate
- Severe
22. Sensitive to hot weather
- Mild
- Moderate
- Severe
23. Burning or itching anus
- Mild
- Moderate
- Severe
24. Crave sweets
- Mild
- Moderate
- Severe
Group 6:
1. Loss of taste for meat
- Mild
- Moderate
- Severe
2. Lower bowel gas several hours after eating
- Mild
- Moderate
- Severe
3. Burning stomach sensations, eating relieves
- Mild
- Moderate
- Severe
4. Coated tongue
- Mild
- Moderate
- Severe
5. Pass large amounts of foul smelling gas
- Mild
- Moderate
- Severe
6. Indigestion 1/2 - 4 hours after eating
- Mild
- Moderate
- Severe
7. Mucus colitis or "irritable bowel"
- Mild
- Moderate
- Severe
8. Gas shortly after eating
- Mild
- Moderate
- Severe
9. Stomach "bloating" after eating
- Mild
- Moderate
- Severe
Group 7a:
1. Insomnia
- Mild
- Moderate
- Severe
2. Nervousness
- Mild
- Moderate
- Severe
3. Can't gain weight
- Mild
- Moderate
- Severe
4. Intolerance to heat
- Mild
- Moderate
- Severe
5. Highly emotional
- Mild
- Moderate
- Severe
6. Flush easily
- Mild
- Moderate
- Severe
7. Night sweats
- Mild
- Moderate
- Severe
8. Skin is thin and moist
- Mild
- Moderate
- Severe
9. Inward trembling
- Mild
- Moderate
- Severe
10. Heart palpitates
- Mild
- Moderate
- Severe
11. Increased appetite without weight gain
- Mild
- Moderate
- Severe
12. Pulse races when resting
- Mild
- Moderate
- Severe
13. Eyelids and face twitch
- Mild
- Moderate
- Severe
14. Irritable and restless
- Mild
- Moderate
- Severe
15. Can't work under pressure
- Mild
- Moderate
- Severe
Group 7b:
1. Noticeable weight gain
- Mild
- Moderate
- Severe
2. Decrease in appetite
- Mild
- Moderate
- Severe
3. Easily fatigued
- Mild
- Moderate
- Severe
4. Ringing in ears
- Mild
- Moderate
- Severe
5. Sleepy during day
- Mild
- Moderate
- Severe
6. Sensitive to cold
- Mild
- Moderate
- Severe
7. Dry or scaly skin
- Mild
- Moderate
- Severe
8. Constipation
- Mild
- Moderate
- Severe
9. Mental sluggishness
- Mild
- Moderate
- Severe
10. Hair coarse, falls out
- Mild
- Moderate
- Severe
11. Headaches upon arising, wear off during day
- Mild
- Moderate
- Severe
12. Pulse slow, below 65
- Mild
- Moderate
- Severe
13. Frequent urination
- Mild
- Moderate
- Severe
14. Impaired hearing
- Mild
- Moderate
- Severe
15. Reduced initiative
- Mild
- Moderate
- Severe
Group 7c:
1. Failing memory
- Mild
- Moderate
- Severe
2. Low blood pressure
- Mild
- Moderate
- Severe
3. Increased sex drive
- Mild
- Moderate
- Severe
4. Headaches, "splitting or rending" type
- Mild
- Moderate
- Severe
5. Decreased sugar tolerance
- Mild
- Moderate
- Severe
Group 7d:
1. Abnormal thirst
- Mild
- Moderate
- Severe
2. Bloating of the abdomen
- Mild
- Moderate
- Severe
3. Weight gain around hips or waist
- Mild
- Moderate
- Severe
4. Sex drive reduced or lacking
- Mild
- Moderate
- Severe
5. Tendency toward ulcers and/or colitis
- Mild
- Moderate
- Severe
6. Increased sugar tolerance
- Mild
- Moderate
- Severe
7. (FEMALE) Menstrual disorders
- Mild
- Moderate
- Severe
8. (YOUNG GIRLS) Lack of menstrual function
- Mild
- Moderate
- Severe
Group 7e:
1. Dizziness
- Mild
- Moderate
- Severe
2. Headaches
- Mild
- Moderate
- Severe
3. Hot flashes
- Mild
- Moderate
- Severe
4. Increased blood pressure
- Mild
- Moderate
- Severe
5. (FEMALE) Hair growth on face or body
- Mild
- Moderate
- Severe
6. Sugar in urine (not diabetes)
- Mild
- Moderate
- Severe
7. (FEMALE) Masculine tendencies
- Mild
- Moderate
- Severe
Group 7f:
1. Weakness and/or dizziness
- Mild
- Moderate
- Severe
2. Chronic fatigue
- Mild
- Moderate
- Severe
3. Low blood pressure
- Mild
- Moderate
- Severe
4. Nails weak and/or ridged
- Mild
- Moderate
- Severe
5. Tendency towards hives
- Mild
- Moderate
- Severe
6. Arthritic tendencies
- Mild
- Moderate
- Severe
7. Perspiration increase
- Mild
- Moderate
- Severe
8. Bowel disorders
- Mild
- Moderate
- Severe
9. Poor circulation
- Mild
- Moderate
- Severe
10. Swollen ankles
- Mild
- Moderate
- Severe
11. Crave salt
- Mild
- Moderate
- Severe
12. Brown spots or bronzing of skin
- Mild
- Moderate
- Severe
13. Allergies - tendency to asthma
- Mild
- Moderate
- Severe
14. Weakness after colds or influenza
- Mild
- Moderate
- Severe
15. Muscular and nervous exhaustion
- Mild
- Moderate
- Severe
16. Respiratory disorders
- Mild
- Moderate
- Severe
16. Respiratory disorders
- Mild
- Moderate
- Severe
Group 8:
1. Apprehension
- Mild
- Moderate
- Severe
2. Irritability
- Mild
- Moderate
- Severe
3. Morbid fears
- Mild
- Moderate
- Severe
4. Never seems to get well
- Mild
- Moderate
- Severe
5. Forgetfulness
- Mild
- Moderate
- Severe
6. Indigestion
- Mild
- Moderate
- Severe
7. Poor appetite
- Mild
- Moderate
- Severe
8. Craving for sweets
- Mild
- Moderate
- Severe
9. Muscular soreness
- Mild
- Moderate
- Severe
10. Depression; feelings of dread
- Mild
- Moderate
- Severe
11. Noise sensitivity
- Mild
- Moderate
- Severe
12. Acoustic hallucinations
- Mild
- Moderate
- Severe
13. Tendency to cry without reason
- Mild
- Moderate
- Severe
14. Hair is coarse and/or thinning
- Mild
- Moderate
- Severe
15. Weakness
- Mild
- Moderate
- Severe
16. Fatigue
- Mild
- Moderate
- Severe
17. Skin sensitive to touch
- Mild
- Moderate
- Severe
18. Tendency towards hives
- Mild
- Moderate
- Severe
19. Nervousness
- Mild
- Moderate
- Severe
20. Headache
- Mild
- Moderate
- Severe
21. Insomnia
- Mild
- Moderate
- Severe
22. Anxiety
- Mild
- Moderate
- Severe
23. Anorexia
- Mild
- Moderate
- Severe
24. Inability to concentrate; confusion
- Mild
- Moderate
- Severe
25. Frequent stuffy nose; sinus infections
- Mild
- Moderate
- Severe
26. Allergy to some foods
- Mild
- Moderate
- Severe
27. Loose joints
- Mild
- Moderate
- Severe
28. Anxiety
- Mild
- Moderate
- Severe
FEMALE ONLY:
1. Very easily fatigued
- Mild
- Moderate
- Severe
2. Premenstrual tension
- Mild
- Moderate
- Severe
3. Painful menses
- Mild
- Moderate
- Severe
4. Depressed feelings before menstruation
- Mild
- Moderate
- Severe
5. Excessive and prolonged menstruation
- Mild
- Moderate
- Severe
6. Painful breasts
- Mild
- Moderate
- Severe
7. Menstruate too frequently
- Mild
- Moderate
- Severe
8. Vaginal discharge
- Mild
- Moderate
- Severe
9. Hysterectomy/ovaries removed
- Mild
- Moderate
- Severe
10. Menopausal hot flashes
- Mild
- Moderate
- Severe
11. Menses scanty or missed
- Mild
- Moderate
- Severe
12. Acne, worse at menses
- Mild
- Moderate
- Severe
13. Long standing depression
- Mild
- Moderate
- Severe
MALE ONLY:
1. Prostate trouble
- Mild
- Moderate
- Severe
2. Urination difficult or dribbling
- Mild
- Moderate
- Severe
3. Frequent night-time urination
- Mild
- Moderate
- Severe
4. Depression
- Mild
- Moderate
- Severe
5. Pain on inside of legs or heels
- Mild
- Moderate
- Severe
6. Feeling of incomplete bowel evacuation
- Mild
- Moderate
- Severe
7. Lack of energy
- Mild
- Moderate
- Severe
8. Migrating aches and pains
- Mild
- Moderate
- Severe
9. Too easily tired
- Mild
- Moderate
- Severe
10. Avoids activity
- Mild
- Moderate
- Severe
11. Leg nervousness at night
- Mild
- Moderate
- Severe
12. Diminished sex drive
- Mild
- Moderate
- Severe
13. List your top 5 main physical complaints in order of importance:
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(801) 298-1812

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Dental Solutions, Inc
Dr. Judson Wall
235 S 400 E
Bountiful, UT
84010
Phone: (801) 298-1812

About Our Practice

Meet Dr. Wall
Meet The Staff
Patient Testimonials
Before and After Photos
Financial Policy
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Featured Treatments

Mercury Free Dentistry
Root Canal Removal
Cavitation Surgery
Pinhole Surgical Technique
Zirconia Dental Implants
Digital Impressions
CARESTREAM
One Visit Crowns

Dr Montes seen both of my kids and was absolutely amazing, they felt no pain, very comfortable the whole time. They loved it there! They were both scared to go and now they both can't wait to go back!

Kierston Kirby

May 24, 2022.

I feel very fortunate to have found Dental Solutions. The dentists and the staff are outstanding! I have had health issues for many years and had this underlying, nagging feeling that was just exhausting. I went to Dental Solutions and had cavitation surgery and other dental work clean up, and that underlying nagging feeling is gone and my energy has returned! I would highly recommend them.

Tina Clifford

June 28, 2021.

The doctors and supporting staff are wonderful, and have helped me take control of my health through corrective dental work. It’s so nice to have a consultation with professionals who really care about you and your life!

Bonita Richins

June 18, 2021.

Dr Montes is a very knowledgeable dentist, and the whole staff is very fun and professional.

Coz

June 14, 2021.

The doctors and staff at Dental Solutions are exceptional. I have been going since 2015 and have received the best of care. Dr. Wall is a great dentist with much knowledge and expertise. He and the staff make sure you are comfortable and have all your questions answered. Kris is the best and most thorough hygienist. Highly recommend!

Marianne Austin

June 2, 2021.

Dr. Wall is a living legend in our family! He has helped me recover from poorly done root canals, fixed years worth of incorrect orthodontics, and solved my TMJ problems. I struggled with chronic vertigo during and after my pregnancy that was passed off as “normal” hormonal changes. I saw multiple doctors and neurologists before visiting Dr. Wall. He discovered 4 cavitations that needed addressing and once he worked his dental magic, the vertigo I had struggled with daily for 2 years disappeared! The importance of proper dental care for overall health cannot be overlooked. Dr. Wall is the best in his field and it’s an honor to have him on my healthcare team!

Missy Beavers

May 26, 2021.

I highly recommend Dr. Wall to anybody with tooth aches or pains. He is so caring and understanding. He has genuine concern for my well being. His staff is very nice and professional. I can't say enough good things about the care I received from Dr. Judson Wall and his team. Thank-you!

Tyler Heath

May 26, 2021.

I had so much discomfort for years and Dr Wall took out teeth that were gangrene that I did not know were that bad. He is amazing....

Beatrice Ireland

May 24, 2021.

Hands down the most amazing dentist I've ever been to. From the expertise of care and heartfelt communication from Dr. Wall and his staff to the lush jungle of plants throughout the office, this is a dental experience like no other. For 15 years I had been struggling with a phantom disease causing chronic fatigue, brain fog, anxiety, depression, etc...it was hell. A woman (who I now feel is certainly a guardian angel) brought to my attention that my story was almost identical to the man who produced the film "Root Cause". I was taken aback that my issues could actually be caused by an old root canal I had and felt compelled to watch it...it made me cry and I knew this was it. She then referred me to Dr. Wall and the rest is history. I spent about 4 hours at Dental Solutions my first visit where I received a level of care you wouldn't expect from a dentist, let alone your family doctor. Being a biological practice, Dental Solutions has your whole body in mind and I was tested from head to toe to figure out what was going wrong. Sure enough, I had a failed root canal that had eaten a 1 cm diameter hole in my jaw above that tooth...it was slowly killing me. Dr. Wall pulled the decayed tooth which was gangrenous, cleaned everything out, stuffed the decayed hole with platelet rich fiber (PRF) and put a zirconia implant in. He also cleaned out my wisdom tooth cavitations and did TMJ injections to help the jaw issues I didn't realize I had. Over one year later and I feel better than ever, I have my vitality back!!!! So very thankful for Dr. Wall, he saved my life. No other dentist had any idea what was going on. This is the place to go, I travel from Colorado to come here...highly recommend this practice. Thank you Dental Solutions for changing my life!

Alex Curry

May 13, 2021.

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