Symptom Survey

Please rate each of the following symptoms based upon your typical health profile for the past 30 days.

Point Scale

0 = Never or almost never have the symptoms
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe

General Information
Name
Digestive Tract
Nausea or vomiting
Diarrhea
Constipation
Bloated feeling
Belching, or passing gas
Heartburn
Total
Ear
Itchy ears
Ear aches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total
Emotions
Mood swings
Anxiety, fear or nervousness
Anger, irritability, or aggressiveness
Depression
Total
Energy / Activity
Fatigue
Apathy, lethargy
Hyperactivity
Restlessness
Total
Eyes
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near or far sightedness)
Total
Head
Headaches
Faintness
Dizziness
Insomnia
Total
Heart
Irregular or skipped heartbeat
Rapid or pounding heart beat
Chest pain
Total
Joint / Muscles
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total
Lungs
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total
Mind
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total
Mouth / Throat
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total
Nose
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total
Skin
Acne
Hives, rashes, or dry skin
Hair loss
Flushing or hot flashes
Excessive sweating
Total
Weight
Binge eating / drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Total
Other
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total
Grand Total

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