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0 of 76 rated
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If you have had a symptom, mark it with at least a 1. Answer what it was like when you had it.
If this is your second or subsequent time filling this out and it is for the Past 7 Days, skip whatever question(s) that do not pertain as you read them to allow for a faster process.
Never
0 – Never or almost never have the symptom
Occasionally
1 – Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
Frequently
3 – Frequently have it, effect is not severe
4 – Frequently have it, effect is severe
Section total 0/20
Headaches
Faintness
Dizziness
Insomnia
Light headed
Section total 0/16
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Section total 0/24
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears
Hearing loss
Loss of balance
Stuffy nose
Sinus problems
Excessive mucus formation
Hay fever
Allergic sinus reaction to weed, grass, or tree pollens: frequent sneezing, runny & stuffy nose, red, itchy, or watery eyes; itchy throat, nose, ears; tired from poor sleep
Sneezing attacks
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Sore blisters on your lips or tongue
Acne
Hives, rashes, dry skin
Flushing, hot flashes
Excessive sweating
Hair loss
Section total 0/12
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Section total 0/28
Nausea, vomiting
Diarrhea
Intestinal/stomach pain
Constipation
It's hard to poop, or you go every 2 plus days
Bloated feeling
Belching, passing gas
Heartburn
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in joints
Pain or aches in muscles
Arthritis pain that is diagnosed
Arthritis pain that is not diagnosed
Binge eating/drinking
Craving certain foods
Excessive weight
Underweight / weight loss
Water retention
Swelling in your hands, fingers, belly, legs, feet
Compulsive eating
Feel like you always have to eat
Fatigue, sluggishness
Apathy, lethargy
You don't care & don't feel like doing things
Hyperactivity
Restlessness
Section total 0/36
Poor memory
Confusion, poor comprehension
Difficulty in making decisions
Stuttering or stammering
Repeating or stretching out letters, words, or sounds; silent pauses of the voice. All to do with speech
Poor physical coordination
Concussion, blackouts, lightheaded
Slurred speech
Your words are mumbled, unclear, or distorted because your mouth & throat muscles cannot move properly
Learning disabilities
Poor concentration
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Grand total so far
0 out of 3040/304
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