自律神經失調問卷表

                                                                                                                    當自律神經失調時,所產生的症狀很多,在全身各個部位都可能產生,您可以使用以下問卷表來做自我診斷:
-------------------------門診問卷表--------------------------------

姓名:______________ 病歷號碼:______________ 填表日期:___年___月___日

您最近是否出現以下的症狀呢?符合的打○,特別嚴重的畫◎。

1.心理倦怠__________31.喉嚨疼痛____________61.經常排氣___________

 

2.生理疲倦__________32.喉嚨很嗆____________62.腰痛_______________

3.身體無力__________33.喉嚨很乾____________63.腳寒冷_____________

4.盜汗______________34.經常出現口內炎______64.腳發燙_____________

5.容易感冒__________35.反覆出現扁桃腺炎____65.膝痛_______________

6.感冒很難治好______36.舌頭疼痛____________66.腳抽筋_____________

7.容易暈車__________37.嚐不出味道__________67.腳發麻_____________

8.手腳冰冷症________38.打噴嚏______________68.腳浮腫_____________

9.冒汗(全身、手)_____39.流鼻水______________69.皮膚皸裂__________

10.不出汗___________40.鼻塞________________70.皮膚凍傷___________

11.焦躁_____________41.聞不到氣味__________71.長雞眼_____________

12.易怒_____________42.打鼾________________72.皮膚發癢___________

13.憂鬱_____________43.磨牙________________73.脫毛較多___________

14.不易熟睡_________44.頸部、肩膀酸痛______74.經常出現蕁麻疹_____

15.睡眠較淺_________45.背部酸痛____________75.容易長濕疹_________

16.早上起床不舒服___46.狐臭________________76.指甲剝落、破裂_____

17.頭痛_____________47.手發麻______________77.有香港腳___________

18.頭重感___________48.手顫抖______________78.慢性便秘___________

19.血氣上衝_________49.血壓高______________79.經常下痢___________

20.思緒不集中_______50.血壓低______________80.下痢便秘交互出現___

21.臉疼痛___________51.胸苦悶______________81.頻尿_______________

22.頭暈_____________52.心悸________________82.曾經尿失禁_________

23.起立性昏眩_______53.呼吸困難____________83.夜間多尿___________

24.眼睛模糊_________54.沒有食慾____________84.有殘尿感___________

25.眼睛疲勞_________55.胃腸較弱____________85.性慾減退___________

26.視力減退_________56.胃部不快感__________86.陽痿_______________

27.眼睛發癢_________57.胃灼熱______________87.生理不順___________

28.眼睛乾燥_________58.噁心________________88.生理痛嚴重_________

29.耳鳴_____________59.常打飽嗝____________89.因不孕症而煩惱_____

30.耳朵聽不清楚_____60.肚子發脹____________90.有痔瘡的困擾_______

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