Initial Symptom Survey

Score every symptom based on your experience over the past month.

If you did not suffer from the symptom ever or almost never, leave it at "—".

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

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)

Grand Total

0