Symptoms Questionnaire

Personal Information

 

Instructions

  • Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years
    If multiple choices are given, please specify what applies in the comment column.

    • Leave the score blank if you Never have the symptom.                          
    • Use a 1 if you Occasionally have it and the effect is Mild.
    • Use a 2 if you Occasionally have it and the effect is Severe.
    • Use a 3 if you Frequently or Consistently have it and the effect is Mild
    • Use a 4 if you Frequently or Consistently have it and the effect is Severe.
 

Head

 

Nose

 

Mouth

 

Skin

 

Heart

 

Lungs

 

Digestion

 

Joints and Muscles

 

Weight

 

Energy

 

Mind

 

Mood

 

Miscellaneous

 

Verification