Symptom Survey - EPIC Functional Medicine

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Name* This field is required.

First Name

Last Name

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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.

6

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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11

Head Total

12

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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14

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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15

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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16

Eyes Total

17

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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18

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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19

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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1

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20

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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1

2

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21

Ears Total

22

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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1

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4

23

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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1

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24

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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25

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

0

1

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4

26

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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27

Nose Total

28

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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1

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4

29

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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30

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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31

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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1

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32

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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1

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33

Mouth Total

34

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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1

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35

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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1

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36

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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1

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37

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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1

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38

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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39

Skin Total

40

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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1

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41

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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1

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42

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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43

Heart Total

44

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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1

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45

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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1

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4

46

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

0

1

2

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4

47

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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1

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48

Lungs Total

49

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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1

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50

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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1

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51

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

0

1

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52

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

0

1

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4

53

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

0

1

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54

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

0

1

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4

55

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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1

2

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4

56

Digestive Tract Total

57

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

0

1

2

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4

58

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

0

1

2

3

4

59

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

0

1

2

3

4

60

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

0

1

2

3

4

61

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

0

1

2

3

4

62

Joints Muscle Total

63

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

0

1

2

3

4

64

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

0

1

2

3

4

65

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

0

1

2

3

4

66

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

0

1

2

3

4

67

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

0

1

2

3

4

68

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

0

1

2

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4

69

Weight Total

70

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

0

1

2

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4

71

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

0

1

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3

4

72

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

0

1

2

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4

73

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

0

1

2

3

4

74

Energy/activity Total

75

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

0

1

2

3

4

76

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

0

1

2

3

4

77

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

0

1

2

3

4

78

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

0

1

2

3

4

79

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

0

1

2

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4

80

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

0

1

2

3

4

81

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

0

1

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4

82

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

0

1

2

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4

83

Mind Total

84

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

0

1

2

3

4

85

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

0

1

2

3

4

86

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

0

1

2

3

4

87

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

0

1

2

3

4

88

Emotions Total

89

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

0

1

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4

90

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

0

1

2

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4

91

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

0

1

2

3

4

92

Other Total

93

Grand Total Multi Symptom Questionnaire

94

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

0

2

5

10

95

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

0

2

5

10

96

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

0

2

5

10

97

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

5

10

98

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

99

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

0

2

5

10

100

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

0

2

5

10

101

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

0

2

5

10

102

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

5

10

103

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

5

10

104

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

105

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

106

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

107

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

108

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

109

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

110

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

111

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

112

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

113

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

114

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

115

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

5

10

116

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

117

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

118

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

119

Grand Total Thyroid Symptom Questionnaire

120

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

121