Symptom Tracker

1
Name* This field is required.
First Name
Last Name
2
Date* This field is required.
Date
Month
Day
Year
3
INSTRUCTIONS: Please read through the list of symptoms and rate each of them to the best of your ability. Make sure these are related to your current symptoms that you are experiancing. Down below expains how the rating list is calculated.

0 = None 2 = Mild 4 = Severe 6 = Very Severe
4
Calculation
5
Headache* This field is required.
0
1
2
3
4
5
6
None
Max
6
Nausea/Vomiting* This field is required.
0
1
2
3
4
5
6
None
Max
7
Balance Problems* This field is required.
0
1
2
3
4
5
6
None
Max
8
Dizziness* This field is required.
0
1
2
3
4
5
6
None
Max
9
Fatigue* This field is required.
0
1
2
3
4
5
6
None
Max
10
Trouble Falling Asleep* This field is required.
0
1
2
3
4
5
6
None
Max
11
Excessive Sleeping* This field is required.
0
1
2
3
4
5
6
None
Max
12
Loss of Sleep* This field is required.
0
1
2
3
4
5
6
None
Max
13
Drowsiness* This field is required.
0
1
2
3
4
5
6
None
Max
14
Light Sensitivity* This field is required.
0
1
2
3
4
5
6
None
Max
15
Noise Sensitivity* This field is required.
0
1
2
3
4
5
6
None
Max
16
Irritability* This field is required.
0
1
2
3
4
5
6
None
Max
17
Sadness* This field is required.
0
1
2
3
4
5
6
None
Max
18
Nervousness/Anxiety* This field is required.
0
1
2
3
4
5
6
None
Max
19
More Emotional* This field is required.
0
1
2
3
4
5
6
None
Max
20
Frustration/Anger* This field is required.
0
1
2
3
4
5
6
None
Max
21
Numbness* This field is required.
0
1
2
3
4
5
6
None
Max
22
Feeling Foggy* This field is required.
0
1
2
3
4
5
6
None
Max
23
Feeling Slow* This field is required.
0
1
2
3
4
5
6
None
Max
24
Difficulty Concentrating* This field is required.
0
1
2
3
4
5
6
None
Max
25
Difficulty Remembering* This field is required.
0
1
2
3
4
5
6
None
Max
26
Visual Problems* This field is required.
0
1
2
3
4
5
6
None
Max
27
28
Should be Empty: