Symptom Questionnaire
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
For each symptom listed below, please choose one response. If you don't experience the symptom, select "N/A." If you do currently experience the symptom, please rate the symptom on a scale from 1 to 5 by choosing the number that indicates the degree to which you experience it (1 = minimal, 5 = extreme).
*
N/A
1
2
3
4
5
Fatigue
__________________
Weakness
Inability to retain new info
Aches
Headache
Light sensitivity
__________________
Memory impairment
Decreased word finding
__________________
Difficulty concentrating
__________________
Joint pain
Morning stiffness
Cramps
__________________
Unusual skin sensitivity
Tingling
__________________
Shortness of breath
Sinus congestion
__________________
Cough
Excessive thirst
Confusion
__________________
Appetite swings
Irregular body temp
Increased urination
__________________
Red eyes
Blurred vision
Night sweats
Mood swings
Ice-pick pain
__________________
Abdominal pain
Diarrhea
Numbness
__________________
Watery eyes
Disorientation
Metallic taste
__________________
Static shocks
Vertigo
If you have been working with us for a while, please tell us how your symptoms compare to when you first started with us:
Any additional comments you'd like to share?
Indigo Functional Medicine Solutions
678-590-8082 www.indigofms.com
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