• Initial Symptom Survey

  • INSTRUCTIONS: Score every symptom based on your experience OVER THE PAST MONTH. Using the SCALE OF SYMPTOM POINTS listed below, click the appropriate number to the right of every symptom listed. Enter the Grand Total in the box.

  • SCALE OF SYMPTOM POINTS

    If you did not suffer from the symptom ever or almost never, leave it at zero

    1 = OCCASIONALLY (less than 2 times per week) and symptom was MILD

    2 = FREQUENTLY (2 or more times per week) and symptom was MILD

    3 = OCCASIONALLY (less than 2 times per week) and symptom was SEVERE

    4 = FREQUENTLY (2 or more times per week) and symptom was SEVERE

  • CONSTITUTIONAL

  • EMOTIONAL/MENTAL

  • HEAD/EARS

  • SKIN

  • NASAL/SINUS

  • MOUTH/THROAT

  • LUNGS

  • EYES

     

     

     

     

  • GENITOURINARY

  • MUSCULOSKELETAL

  • CARDIOVASCULAR

  • DIGESTIVE

  • WEIGHT MANAGEMENT

     

     

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