Chronic Inflammatory Response Syndrome

Chronic Inflammatory Response Syndrome - Clinical Questionnaire
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
Date
Please answer YES or NO for each symptom
CATEGORY 1

Fatigue
Subtotal:
CATEGORY 2

WeaknessDecreased assimilation of new knowledgeAchesHeadachesLight sensitivity
Subtotal:
CATEGORY 3

Memory impairmentDecreased word finding
Subtotal:
CATEGORY 4

Difficulty concentrating
Subtotal:
CATEGORY 5

Joint painA.M. stiffnessCramps
Subtotal:
CATEGORY 6

TinglingTremorsUnusual skin sensitivity
Subtotal:
CATEGORY 7

Shortness of breathSinus congestion
Subtotal:
CATEGORY 8

CoughExcessive thirstConfusion
Subtotal:
CATEGORY 9

Appetite swingsDifficulty regulating temperatureIncreased urinary function
Subtotal:
CATEGORY 10

Red eyesBlurred visionSweats (night)Mood swingsIce-pick pain
Subtotal:
CATEGORY 11

Abdominal painDiarrhoeaNumbness
Subtotal:
CATEGORY 12

Tearing of eyesDisorientationMetallic taste
Subtotal:
CATEGORY 13

Static shocksVertigo
Subtotal:
QUESTIONNAIRE TOTAL:
TOTAL NUMBER OF CATEGORIES THAT HAVE SYMPTOMS:
Should be Empty:

Chronic Inflammatory Response Syndrome - Clinical Questionnaire