Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale:

0 - Never or almost never have the symptom

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

Headache *

Faintness *

Dizziness *

Point Scale:

0 - Never or almost never have the symptom

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

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) *

Itchy ears *

Earaches, ear infections *

Drainage from ear *

Ringing in ears, hearing loss *

Point Scale:

0 - Never or almost never have the symptom

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

Stuffy nose *

Sinus problems *

Sneezing attacks *

Hay fever *

Excessive mucus formation *

Chronic coughing *

Gagging, frequent need to clear throat *

Sore throat, hoarseness, loss of voice *

Swollen or discolored tongue, gums, lips *

Canker sores *

Point Scale:

0 - Never or almost never have the symptom

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

Hives, rashes, dry skin *

Hair loss *

Excessive sweating *

Flushing, hot flashes *

Irregular or skipped heartbeat *

Rapid or pounding heartbeat *

Chest pain *

Point Scale:

0 - Never or almost never have the symptom

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

Chest congestion *

Asthma, bronchitis *

Shortness of breath *

Difficulty breathing *

Nausea, vomiting *

Diarrhea *

Constipation *

Bloated feeling *

Belching, passing gas *

Heartburn *

Intestinal/stomach pain *

Point Scale:

0 - Never or almost never have the symptom

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

Pain or aches in joints *

Arthritis *

Stiffness or limitation of movement *

Pain or aches in muscles *

Feeling of weakness or tiredness *

Binge eating/drinking *

Craving certain foods *

Excessive weight *

Compulsive eating *

Water retention *

Underweight *

Point Scale:

0 - Never or almost never have the symptom

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

Fatigue, sluggishness *

Apathy, lethargy *

Hyperactivity *

Restlessness *

Poor memory *

Confusion, poor comprehension *

Poor concentration *

Poor physical coordination *

Difficulty in making decisions *

Stuttering or stammering *

Slurred speech *

Learning disabilities *

Point Scale:

0 - Never or almost never have the symptom

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

Mood swings *

Anxiety, fear, nervousness *

Anger, irritability, aggressiveness *

Depression *

Frequent illness *

Frequent or urgent urination *

Genital itch or discharge *

Please describe any other symptom:

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