Patient Number:
Patient Name:

INSTRUCTIONS: Please fill in the following form completely. Score every symptom based on your experience since your last Symptom Survey. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score in the corresponding field for EVERY symptom listed.

SCALE OF SYMPTOMS POINTS Select option 0 Did Not Suffer From This Ever or Almost Ever Select option 1 Suffered OCCASSIONALLY (less than 2 times per week), symptom wasn’t severe Select option 2 Suffered FREQUENTLY (2 or more times per week), symptom wasn’t severe Select option 3 Suffered OCCASSIONALLY and symptom was severe Select option 4 Suffered FREQUENTLY and symptom was severe  EXAMPLE   0    1     2    3    4 select value associated effect

CONSTITUTIONAL SYMPTOMS

0    1    2   3    4
	Fatigue (tired, sluggish)
	Hyperactive (nervous energy)
	Restless (can't relax/sit still)
	Sleepiness during day
	Insomnia at night
	Malaise (feel lousy)

LUNGS

0    1    2   3    4
	"Wheezing" (Asthma/ Asthma-Like Symptoms)
	Chest Congestion
	"Non-Productive" Coughing
	"Productive" Coughing

EMOTIONAL/MENTAL SYMPTOMS

0    1    2   3    4
	Depression (feelings of hopelessness)
	Anxiety (vague fears, uneasiness)
	Mood Swings (rapid, distinct changes)
	Irritability (anger, hostility)
	Forgetfulness
	Lack of Concentration/Focus

EYES

0    1    2   3    4
	Red or Swollen Eyes
	Watery Eyes
	Itchy Eyes
	"Dark Circles" or "Baggy"

GENITOURINARY

0    1    2   3    4
	Increased Urinary Frequency
	Painful Urination

HEAD/EARS

0    1    2   3    4
	Headache (any kind)
	Earache
	Ear Infection
	Ringing in Ear
	Itchy Ears
	Discharge from Ear

MUSCULOSKELETAL

0    1    2   3    4
	Joint Pains/Aching
	Stiff Joints
	Muscle Aches
	Stiff Muscles

SKIN

0    1    2   3    4
	Blemishes, Acne
	Rashes, Hives
	Eczema
	"Rosy" Cheeks

CARDIOVASCULAR

0    1    2   3    4
	Irregular Heartbeat
	High Blood Pressure (Diagnosed)

NASAL/SINUS

0    1    2   3    4
	Post Nasal Drip
	Sinus Pain
	Runny Nose
	Stuffy Nose
	Sneezing

DIGESTIVE

0    1    2   3    4
	Heartburn/Esoph. Reflux
	Stomach Pains/Cramps
	Intestinal Pains/Cramps
	Constipation
	Diarrhea
	Bloating Sensation
	Gas (of Any Kind)
	Nausea, Vomiting
	Painful Elimination

MOUTH/THROAT

0    1    2   3    4
	Sore Throat
	Swollen Throat
	Swelling of Lips/Tongue
	Gagging or Throat "Clearing"
	Lesions ("Canker Sores")

WEIGHT MANAGEMENT

0    1    2   3    4
	Record Actual Weight
	Fluctuating Weight
	Food Cravings
	Water Retention
	Binge Eating or Drinking
	Purging (all methods)