Initial Symptom Survey
INSTRUCTIONS: Score every symptom based on your experience OVER THE PAST MONTH. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score to the left of EVERY symptom listed.
Email address *
Date: *
MM
/
DD
/
YYYY
Patient Name: *
Your answer
SCALE OF SYMPTOM POINTS
N/A = Not Applicable
0 = IF you did not suffer from the symptom ever or almost never
1 = OCCASIONALLY (less than 2 times per week) and symptom was MILD
2 = FREQUENTLY (2 or more times per week) and symptom was MILD
3 = OCCASIONALLY (less than 2 times per week) and symptom was SEVERE
4 = FREQUENTLY (2 or more times per week) and symptom was SEVERE
CONSTITUTIONAL
0
1
2
3
4
Fatigue (sluggish, tired)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Daytime sleepiness
Insomnia at night
Malaise (feeling lousy)
Seizures
TOTAL (0-28)
Your answer
EMOTIONAL/MENTAL
0
1
2
3
4
Depression
Anxiety (fears, uneasiness)
Mood swings (rapid changes)
Irritability
Forgetfulness
Lack of concentration/Brain fog
Low sex drive
TOTAL (0-28)
Your answer
HEAD/EARS
0
1
2
3
4
Headache (not migraine)
Migraine
Earache
Ear infection
Ringing in ears
Itchy ears
Discharge from ears
Sensitivity to sound
TOTAL (0-32)
Your answer
SKIN
0
1
2
3
4
Blemishes, acne
Rashes or hives
Eczema or psoriasis
“Rosy” cheeks
Flushing
Itchy skin
TOTAL (0-24)
Your answer
NASAL/SINUS
0
1
2
3
4
Post nasal drip
Sinus pain
Runny nose
Stuffy nose
Sneezing
TOTAL (0-20)
Your answer
MOUTH/THROAT
0
1
2
3
4
Sore throat
Swollen throat
Swelling/burning lips/tongue
Gagging/throat clearing
Canker sores
Difficulty swallowing
TOTAL (0-24)
Your answer
LUNGS
0
1
2
3
4
Wheezing
Chest congestion
Dry cough
Wet cough
Shortness of breath
TOTAL (0-20)
Your answer
EYES
0
1
2
3
4
Red or swollen eyes
Watery eyes
Itchy eyes
Dark circles or “bags”
Sensitivity to light
Aura
TOTAL (0-24)
Your answer
GENITOURINARY
0
1
2
3
4
Increased urinary frequency
Painful urination
Bladder pain
Bedwetting
TOTAL (0-16)
Your answer
MUSCULOSKELETAL
0
1
2
3
4
Joint pains
Stiff joints
Muscle aches
Stiff muscles
Tics (facial or otherwise)
Muscle spasms
Muscle cramps
TOTAL (0-28)
Your answer
CARDIOVASCULAR
0
1
2
3
4
Irregular heartbeat
High blood pressure
TOTAL (0-8)
Your answer
DIGESTIVE
0
1
2
3
4
Heartburn/reflux
Stomach pains/cramps
Intestinal pains/cramps
Constipation
Diarrhea
Bloating sensation
Gas (of any kind)
Nausea
Vomiting
Painful elimination
TOTAL (0-40)
Your answer
WEIGHT MANAGEMENT
0
1
2
3
4
Fluctuating weight
Food cravings
Water retention
Binge eating or drinking
Purging (all methods)