Symptom Survey - Radiant Life • Radiant Health

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First Name* This field is required.

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Last Name* This field is required.

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Email* This field is required.

example@example.com

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Phone Number

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Date* This field is required.

Date

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How did you hear about us?* This field is required.

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Who referred you?Hit Next If Does Not Apply

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Headaches* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Faintness* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Dizziness* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Insomnia* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Head Total

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Watery or Itchy Eyes* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Swollen, reddened or sticky eyelids* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Bags or dark circles under the eyes* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Blurred or tunnel vision (does not include near or far-sightedness)* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Eyes Total

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Itchy ears* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Earaches, ear infections* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Drainage from ears* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Ringing in ears, hearing loss* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Ears Total

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Stuffy nose* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Sinus problems* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Hay Fever* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Sneezing attacks* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Excessive mucus formation* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Nose Total

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Chronic coughing* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Gagging, frequent need to clear throat* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Sore throat, hoarseness, loss of voice* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Swollen or discolored tongue, gums or lips* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Canker sores* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Mouth Total

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Acne* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Hives, rashes, dry skin* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Hair loss* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Flushing, hot flashes* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Excessive sweating* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Skin Total

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Irregular or skipped heartbeat* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Rapid or pounding heartbeat* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Chest pain* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Heart Total

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Chest congestion* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Asthma, bronchitis* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Shortness of breath* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Difficulty breathing* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Lungs Total

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Nausea, vomitingRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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DiarrheaRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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ConstipationRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Bloated feelingRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Belching, passing gasRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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HeartburnRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Intestinal/stomach painRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Digestive Tract Total

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Pain or aches in jointsRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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ArthritisRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Stiffness or limitation of movementRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Pain or aches in musclesRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Feeling of weakness or tirednessRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Joints Muscle Total

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Binge eating/drinkingRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Craving certain foodsRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Excessive weightRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Compulsive eatingRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Water retentionRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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UnderweightRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Weight Total

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Fatigue, sluggishnessRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Apathy, lethargyRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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HyperactivityRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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RestlessnessRate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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75

Energy/activity Total

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Poor memory* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Confusion, poor comprehension* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Poor concentration* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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79

Poor physical coordination* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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80

Difficulty in making decisions* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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81

Stuttering or stammering* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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82

Slurred speech* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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83

Learning disabilities* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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84

Mind Total

85

Mood swings* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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86

Anxiety, fear, nervousness* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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87

Anger, irritability, aggressiveness* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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88

Depression* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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89

Emotions Total

90

Frequent illness* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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91

Frequent or urgent urination* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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Genital itch or discharge* This field is required.Rate Your Symptoms for the following from 0 - 4: 0 = Never Have It 1 = Occasionally, Not Severe 2 = Occasionally, Severe 3 = Frequently, Not Severe 4 = Frequent & Severe

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93

Other Total

94

Grand Total Multi Symptom Questionnaire

95

Are you cold (cold hands/feet)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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96

Do you have a swelling in the neck area?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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2

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10

97

Are you overweight? (10 if over 20 lbs, 5 if 10-19 lbs, 2 if 5-9 lbs)* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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2

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10

98

Can you eat very little and still not lose weight (or you gain weight too easily)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

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10

99

Are you tired all the time?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

100

Do you wake up with headaches/heavy head that wears off as the day progresses?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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2

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10

101

Do you always need a lot of sleep, and even then you don’t feel well rested?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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2

5

10

102

If you sit down during the day do you get tired (energy drops when you stop moving)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

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10

103

Does your energy significantly drop in the afternoon?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

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10

104

Do you rely on caffeine, nicotine, or some other stimulant to keep your energy going?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

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10

105

Women - Are your moods noticeably worse with your menstrual cycle or transition? Men - Do you lack a morning erection (never get one=10, sometimes=5, occasionally=2)* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

106

Does stress cause you to feel irritable too easily (short fuse, low tolerance)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

107

Are you depressed, easily prone to depression, and/or feel less communicative or withdrawn?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

108

Are you prone to depression in the fall or spring?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

109

Does your head feel heavy (and/or your memory/concentration is noticeably declining)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

110

Is the outside portion of your eyebrows thinning (or gone)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

111

Do you have dry skin and/or dry hair?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

112

Do you have rough patches of skin on your elbows?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

113

Is your hair falling out (or less body hair than what you would consider “normal” on your head, legs (especially calves), arms, armpits, eyelids, eyebrows and pubic area)?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

114

Are you prone to constipation (including having to strain to eliminate)?a question* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

115

Do you have numbness in your extremities or have carpal tunnel syndrome?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

116

Are you prone to facial fluid retention, especially around the eyes?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

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10

117

Is your voice hoarse or coarse?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

118

Do you get muscle cramps or have general muscle weakness?* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

119

Do you have high or low cholesterol? (10 if over 250, 5 if 220-249, 2 if 201-219, 0 if 161-200, 10 if under 140, 5 if 141-160)* This field is required.Rate Your Symptoms for the following from 0 - 10: 0 = Never Have It 2 = Occasionally, Not Severe 5 = Frequently, Not Severe 10 = Frequent & Severe

0

2

5

10

120

Grand Total Thyroid Symptom Questionnaire

121

Total Symptom Burden Load (Multi Symptom & Thyroid Symptom Combined)