SYMPTOM QUESTIONAIRE
Date
Please include your name
Birth Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Email
example@example.com
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. HEAD
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
HEADACHE
FAINTNESS
DIZZINESS
INSOMNIA
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. NOSE
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
STUFFY NOSE
SINUS PROBLEMS
HAY FEVER
SNEEZING ATTACKS
EXCESSIVE MUCUS FORMATION
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. MOUTH
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
CHRONIC COUGHING
GAGGING OR FREQUENT NEED TO CLEAR THROAT
SORE THROAT, HOARSENESS, OR LOSS OF VOICE
SWOLLEN OR DISCOLORED TOUNGUE, GUMS, OR LIPS
CHRONIC TOOTH OR GUM PAIN
CHRONIC JAW PAIN
CANKER SORES
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. SKIN
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
ACNE
HIVES OR OTHER ALLERGIC BREAKOUT
RASH OR PERSISTENTLY DRY SKIN
HAIR LOSS
FLUSHING OR HOT FLASHES
FREQUENTLY FEEL COLD
EXCESSIVE SWEATING
PART OF BODY FREQUENTLY FEELING NUMB
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. HEART
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
IRREGULAR OR SKIPPED HEARTBEAT
RAPID OR POUNDING HEARTBEAT
CHEST PAIN
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. LUNGS
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
CHEST CONGESTION
ASTHMA, BRONCHITIS
SHORTNESS OF BREATH
DIFFICULTY BREATHING
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. DIGESTION
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
NAUSEA OR VOMITING
DIARRHEA
CONSTIPATION
BLOATED FEELING
BELCHING, BURPING
PASSING GAS, FLATULENCE
HEARTBURN
INTESTINAL OR STOMACH PAIN
OTHER PAIN IN GI TRACT
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. JOINTS AND MUSCLES
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
PAIN OR ACHES IN JOINTS
ARTHRITIS
STIFFNESS OR LIMITATIONS OF MOVEMENT
PAIN OR ACHES IN MUSCLES
TREMOR OR RESTLESS LEG
FEELING OF WEAKNESS OR TIREDNESS
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. WEIGHT
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
BINGE EATING/DRINKING
CRAVING CERTAIN FOODS
EXCESSIVE WEIGHT
COMPULSIVE EATING
WATER RETENTION
UNDERWEIGHT
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. ENERGY
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
FATIGUE, SLUGGISHNESS
APATHY, LETHARGY
HYPERACTIVITY
RESTLESSNESS
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. MIND
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
POOR MEMORY
CONFUSION, POOR COMPREHENSION
POOR CONCENTRATION OR FOCUS
POOR PHYSICAL COORDINATION
DIFFICUTLY IN MAKING DECISIONS
STUTTERING OR STAMMERING
LEARNING DISABILITIES
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. MOOD
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
MOOD SWINGS
ANXIETY, IRRITABILITY, AGRESSIVENESS
DEPRESSION
OTHER MOOD CHALLENGES
Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. OTHER
OCCASIONALLY
have it and the effect is
MILD
SCORE: 1
OCACASIONALLY
have it and the effect is
SEVERE
SCORE: 2
FREQUENTLY
or
CONSISTENLY
have it and the effect is
MILD
SCORE: 3
FREQUENTLY
or
CONSISTENTLY
have it and the effect is
SEVERE
SCORE: 4
FREQUENT ILLNESS
FREQUENT OR URGEN URINATION
INABILITY TO URINATE OR LOW URINE FLOW
LOW LIBIDO OR OTHER SEXUAL DYSFUNCTION
GENITAL ITCH OR DISCHARGE
WOMEN: BREAST FIBROIDS
WOMEN: PAIN FUL OR TENDER BREASTS
WOMEN: UNTERINE FIBROIDS
2. Please tally of your scores for each column and place total here:
3. Any further comments you with to share
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Initial Patient Review
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An initial symptom and medical history review that considers your health history, dietary habits, food sensitivities, environment and state of mind to discover the root causes of illness and help you heal your body and regain health.
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