Symptom Questionnaire
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Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years.
Use a 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
Headache
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Faintness
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Dizziness
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Insomnia
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Stuffy nose
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Sinus problems
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Hay fever
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Sneezing attacks
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Excessive mucus formation
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Chronic coughing
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Gagging or frequent need to clear throat
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Sore throat, hoarseness, or loss of voice
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Swollen or discolored tongue, gums, or lips
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Chronic tooth or gum pain or jaw pain.Which?
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Canker sores
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Acne
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Hives or other allergic breakout
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Rash or persistently dry skin
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Hair loss
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Flushing and hot flashes
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Frequently feel cold
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Excessive sweating
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Part of body frequently feeling numb. Which?
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Irregular or skipped heartbeat
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Rapid or pounding heartbeat
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Chest pain
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Chest congestion
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Asthma, bronchitis
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Shortness of breath
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Difficulty breathing
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Nausea or vomiting
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Diarrhea
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Constipation
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Bloating feeling
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Belching, burping
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Passing gas, flatulence
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Heartburn
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Intestinal or Stomach pain. Which?
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Other pain in GI tract? Where?
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Pain or aches in joints
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Arthritis
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Stiffness or limitation of movement
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Pain or aches in muscles
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Tremor of Restless leg
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Feeling of weakness or tiredness
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Binge eating/drinking
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Craving certain foods
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Excessive weight
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Compulsive eating
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Water retention
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Underweight
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Fatigue, sluggishness
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Apathy, lethargy
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Hyperactivity
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Restlessness
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Poor memory
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Confusion, poor comprehension
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Poor concentration or focus
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Poor physical coordination
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Difficulty in making decisions
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Stuttering or stammering
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Learning disabilities
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Mood swings
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Anxiety, fear, nervousness
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Anger, irritability, aggressiveness
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Depression
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Other mood challenges?
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Frequent illness
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Frequent of urgent urination
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Inability to urinate or low urine flow
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Low libido or other sexual dysfunction
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Genital itch or discharge
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Women: Breast fibroids
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Women: Painful or tender breasts
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Women: Uterine fibroids
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Any other comments you wish to share?
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