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Complete this before our call so we can spend our time on you, not on starting from scratch.

Score every symptom based on your experience over the past month. If you never or almost never have it, leave it at 0.

1 = Occasionally (less than 2x/week), mild
2 = Frequently (2+x/week), mild
3 = Occasionally (less than 2x/week), severe
4 = Frequently (2+x/week), severe

Cycle

Cycle score: 0 / 32

Score each one based on your last few cycles. If you never or almost never have it, leave it at 0.

1 = Some cycles, mild  ·  2 = Most cycles, mild
3 = Some cycles, severe  ·  4 = Most cycles, severe

Irregular or missing periods

Painful cramps or pain during your cycle

Heavy bleeding or clotting

Spotting between periods

PMS mood swings

Breast tenderness

Unwanted hair growth (chin, face, chest, belly)

Hair thinning on your head

How many days is your cycle, usually?

Are you trying to get pregnant now or in the next year?

Constitutional

Subtotal: 0

Fatigue (sluggish, tired)

Hyperactive (nervous energy)

Restless (can't relax/sit still)

Daytime sleepiness

Insomnia at night

Malaise (feeling lousy)

Seizures

Emotional / Mental

Subtotal: 0

Depression

Anxiety (fears, uneasiness)

Mood swings (rapid changes)

Irritability

Forgetfulness

Lack of concentration / Brain fog

Low sex drive

Head / Ears

Subtotal: 0

Headache (not migraine)

Migraine

Earache

Ear infection

Ringing in ears

Itchy ears

Discharge from ears

Sensitivity to sound

Skin

Subtotal: 0

Blemishes, acne

Rashes or hives

Eczema or psoriasis

"Rosy" cheeks

Flushing

Itchy skin

Nasal / Sinus

Subtotal: 0

Post nasal drip

Sinus pain

Runny nose

Stuffy nose

Sneezing

Mouth / Throat

Subtotal: 0

Sore throat

Swollen throat

Swelling/burning lips/tongue

Gagging/throat clearing

Canker sores

Difficulty swallowing

Lungs

Subtotal: 0

Wheezing

Chest congestion

Dry cough

Wet cough

Shortness of breath

Eyes

Subtotal: 0

Red or swollen eyes

Watery eyes

Itchy eyes

Dark circles or "bags"

Sensitivity to light

Aura

Genitourinary

Subtotal: 0

Increased urinary frequency

Painful urination

Bladder pain

Bedwetting

Musculoskeletal

Subtotal: 0

Joint pains

Stiff joints

Muscle aches

Stiff muscles

Tic nervioso

Muscle spasms

Muscle cramps

Cardiovascular

Subtotal: 0

Irregular heartbeat

High blood pressure

Digestive

Subtotal: 0

Heartburn/reflux

Stomach pains/cramps

Intestinal pains/cramps

Constipation

Diarrhea

Bloating sensation

Gas (of any kind)

Nausea

Vomiting

Painful elimination

Weight Management

Subtotal: 0

Fluctuating weight

Food cravings

Water retention

Binge eating or drinking

Purging (all methods)

Symptom score

0

Cycle score

0