Symptom Survey
Please feel free to skip this form if you do not want to fill this out.
Scale of Symptom Points
Please fill in the following form completely. Score every symptom based on your experience over last 30 days. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score in the corresponding field for EVERY symptom listed.
Not Applicable = If you don't suffer from this ever or almost ever.
1 = Suffered OCCASSIONALLY (less than 2 times per week), symptom wasn't severe
2 = Suffered FREQUENTLY (2 or more times per week), symptom wasn't severe
3 = Suffered OCCASSIONALLY, symptom was severe
4 = Suffered FREQUENTLY, symptom was severe
CONSTITUTIONAL
Fatigue (Sluggish, Tired)
Hyperactive (Nervous energy)
Sleepiness During Day
Insomnia at Night
Malaise (Feel Lousy)
Restless (Can't relax, sit still)
Total (0-24):
0
NASAL/SINUS
Post Nasal Drip
Sinus Pain
Runny Nose
Stuffy Nose
Sneezing
Total (0-20):
0
MUSCULOSKELETAL
Joint Pains/Aching
Stiff Joints
Muscle Aches
Stiff Muscles
Total (0-16):
0
EMOTIONAL/MENTAL
Depression
Anxiety
Mood Swings
Irritability
Forgetfulness
Lack of Concentration/Focus
Total (0-24):
0
MOUTH/THROAT
Sore Throat
Swollen Throat
Swelling of Lips/Tongue
Gagging/Throat Clearing
Canker Sores
Total (0-20):
0
CARDIOVASCULAR
Irregular Heartbeat
High Blood Pressure
Total (0-8):
0
HEAD/EARS
Migraine (Diagnosed)
Headache (Any Kind)
Earache
Ear Infection
Ringing in Ear
Itchy Ears
Discharge from Ears
Total (0-28):
0
LUNGS
Wheezing
Chest Congestion
Dry Cough
Wet Cough
Total (0-16):
0
DIGESTIVE
Heartburn/Reflux
Stomach Pains/Cramps
Intestinal Pains/Cramps
Constipation
Diarrhea
Bloating Sensation
Gas (of Any Kind)
Nausea, Vomiting
Painful Elimination
Total (0-36):
0
SKIN
Blemishes, Acne
Rashes, Hives
Eczema
"Rosy" Cheeks
Total (0-16):
0
EYES
Red or Swollen Eyes
Watery Eyes
Itchy Eyes
Dark �Circle� or �Bags�
Total (0-16):
0
WEIGHT MANAGEMENT
Actual Weight Record
Fluctuating Weight
Food Cravings
Water Retention
Binge Eating or Drinking
Purging (All Methods)
Total (0-24):
0
GENITOURINARY
Increased Urinary Frequency
Painful Urination
Total (0-8):
0

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