SYMPTOMS QUESTIONNAIRE

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years . If multiple choices are given, please specify what applies in the comment column.

  • Leave the score at 0 if you Never have the symptom.
  • Use a 1 if you Occasionally have it and the effect is Mild.
  • Use a 2 if you Occasionally have it and the effect is Severe.
  • Use a 3 if you Frequently or Consistently have it and the effect is Mild
  • Use a 4 if you Frequently or Consistently have it and the effect is Severe.
Name
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Email
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HEAD

Headache
Invalid Input

Comments or Details (if applicable)
Invalid Input

Faintness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Dizziness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Insomnia
Invalid Input

Comments or Details (if applicable)
Invalid Input

Head Symptom Score
Invalid Input

NOSE

Stuffy Nose
Invalid Input

Comments or Details (if applicable)
Invalid Input

Sinus Problems
Invalid Input

Comments or Details (if applicable)
Invalid Input

Hay Fever
Invalid Input

Comments or Details (if applicable)
Invalid Input

Sneezing Attacks
Invalid Input

Comments or Details (if applicable)
Invalid Input

Excessive Mucus Formation
Invalid Input

Comments or Details (if applicable)
Invalid Input

Nose Symptom Score
Invalid Input

MOUTH

Chronic Coughing
Invalid Input

Comments or Details (if applicable)
Invalid Input

Gagging or frequent need to clear throat
Invalid Input

Comments or Details (if applicable)
Invalid Input

Sore throat, hoarseness, or loss of voice
Invalid Input

Comments or Details (if applicable)
Invalid Input

Swollen or discolored tongue, gums, or lips
Invalid Input

Comments or Details (if applicable)
Invalid Input

Tooth ache or gum pain or new dental work
Invalid Input

Comments or Details (if applicable)
Invalid Input

Canker sores
Invalid Input

Comments or Details (if applicable)
Invalid Input

Mouth Symptom Score
Invalid Input

SKIN

Acne
Invalid Input

Comments or Details (if applicable)
Invalid Input

Hives or other allergic breakout
Invalid Input

Comments or Details (if applicable)
Invalid Input

Rash or persistently dry skin
Invalid Input

Comments or Details (if applicable)
Invalid Input

Hair loss
Invalid Input

Comments or Details (if applicable)
Invalid Input

Flushing or hot flashes
Invalid Input

Comments or Details (if applicable)
Invalid Input

Excessive sweating
Invalid Input

Comments or Details (if applicable)
Invalid Input

Frequently feel cold
Invalid Input

Comments or Details (if applicable)
Invalid Input

Part of body frequently feeling numb. Which? (Write in the comment section.)
Invalid Input

Comments or Details (if applicable)
Invalid Input

Skin Symptom Score
Invalid Input

HEART

Irregular or skipped heartbeat
Invalid Input

Comments or Details (if applicable)
Invalid Input

Rapid or pounding heartbeat
Invalid Input

Comments or Details (if applicable)
Invalid Input

Chest pain
Invalid Input

Comments or Details (if applicable)
Invalid Input

Heart Symptom Score
Invalid Input

LUNGS

Chest congestion
Invalid Input

Comments or Details (if applicable)
Invalid Input

Asthma, bronchitis
Invalid Input

Comments or Details (if applicable)
Invalid Input

Shortness of breath
Invalid Input

Comments or Details (if applicable)
Invalid Input

Difficulty breathing
Invalid Input

Comments or Details (if applicable)
Invalid Input

Lungs Symptom Score
Invalid Input

DIGESTION

Nausea or vomiting
Invalid Input

Comments or Details (if applicable)
Invalid Input

Diarrhea
Invalid Input

Comments or Details (if applicable)
Invalid Input

Constipation
Invalid Input

Comments or Details (if applicable)
Invalid Input

Bloated feeling
Invalid Input

Comments or Details (if applicable)
Invalid Input

Belching, burping
Invalid Input

Comments or Details (if applicable)
Invalid Input

Passing gas, flatulence
Invalid Input

Comments or Details (if applicable)
Invalid Input

Heartburn
Invalid Input

Comments or Details (if applicable)
Invalid Input

Intestinal or Stomach pain. Which?
Invalid Input

Comments or Details (if applicable)
Invalid Input

Other pain in GI tract? Where?
Invalid Input

Comments or Details (if applicable)
Invalid Input

Digestion Symptom Score
Invalid Input

JOINTS AND MUSCLES

Pain or aches in joints
Invalid Input

Comments or Details (if applicable)
Invalid Input

Arthritis
Invalid Input

Comments or Details (if applicable)
Invalid Input

Stiffness or limitation of movement
Invalid Input

Comments or Details (if applicable)
Invalid Input

Pain or aches in muscles
Invalid Input

Comments or Details (if applicable)
Invalid Input

Tremor or restless leg
Invalid Input

Comments or Details (if applicable)
Invalid Input

Feeling of weakness or tiredness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Joints and Muscles Symptom Score
Invalid Input

WEIGHT

Binge eating/drinking
Invalid Input

Comments or Details (if applicable)
Invalid Input

Craving certain foods
Invalid Input

Comments or Details (if applicable)
Invalid Input

Excessive weight
Invalid Input

Comments or Details (if applicable)
Invalid Input

Water retention
Invalid Input

Comments or Details (if applicable)
Invalid Input

Underweight
Invalid Input

Comments or Details (if applicable)
Invalid Input

Weight Symptom Score
Invalid Input

ENERGY

Fatigue, sluggishness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Apathy, lethargy
Invalid Input

Comments or Details (if applicable)
Invalid Input

Hyperactivity
Invalid Input

Comments or Details (if applicable)
Invalid Input

Restlessness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Energy Symptom Score
Invalid Input

MIND

Poor memory
Invalid Input

Comments or Details (if applicable)
Invalid Input

Confusion, poor comprehension
Invalid Input

Comments or Details (if applicable)
Invalid Input

Poor concentration or focus
Invalid Input

Comments or Details (if applicable)
Invalid Input

Poor physical coordination
Invalid Input

Comments or Details (if applicable)
Invalid Input

Difficulty in making decisions
Invalid Input

Comments or Details (if applicable)
Invalid Input

Stuttering or stammering
Invalid Input

Comments or Details (if applicable)
Invalid Input

Learning disabilities
Invalid Input

Comments or Details (if applicable)
Invalid Input

Mind Symptom Score
Invalid Input

MOOD

Mood swings
Invalid Input

Comments or Details (if applicable)
Invalid Input

Anxiety, fear, nervousness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Anger, irritability, aggressiveness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Depression
Invalid Input

Comments or Details (if applicable)
Invalid Input

Other mood challenges?
Invalid Input

Comments or Details (if applicable)
Invalid Input

Mood Symptom Score
Invalid Input

OTHER

Frequent illness
Invalid Input

Comments or Details (if applicable)
Invalid Input

Frequent or urgent urination
Invalid Input

Comments or Details (if applicable)
Invalid Input

Inability to urinate or low urine flow
Invalid Input

Comments or Details (if applicable)
Invalid Input

Low libido or other sexual dysfunction
Invalid Input

Comments or Details (if applicable)
Invalid Input

Genital itch or discharge
Invalid Input

Comments or Details (if applicable)
Invalid Input

Women: Breast fibroids
Invalid Input

Comments or Details (if applicable)
Invalid Input

Women: Painful or tender breasts
Invalid Input

Comments or Details (if applicable)
Invalid Input

Women: Uterine/Ovarian fibroids
Invalid Input

Comments or Details (if applicable)
Invalid Input

Other
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Comments or Details (if applicable)
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Other Symptom Score
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TOTAL SYMPTOM SCORE
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