Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Point Scale
0. Never or almost never 1. Occasionally have it not severe 2. Occasionally have it severe 3. Frequently have it not severe 4. Frequently have it severe
Head
Headaches
Faintness
Dizziness
Insomnia
Total:
Eyes
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Total:
Ears
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total:
Nose
Stuffy nose
Sinus problems
Hay fever
Sneezing Attcks
Excessive mucus formation
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:
Skin
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Total:
Heart
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total:
Lungs
Chest Congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total:
Digestive Tract
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total:
Joints/Muscle
Pain or aches in joints
Arthritis
Stiffness or limitatio of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total:
Weight
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Binge eating/drinking
Water retention
Underweight
Total:
Energy/Activity
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total:
Mind
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total:
Emotions
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total:
Other
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total:
Grand Total: Please come back and watch what happens to your score over time!
