Metabolic Recharge Symptom Survey

Metabolic Recharge Symptom Survey

Please take a moment to fill out this survey
Rate each of the following symptoms from zero to four.
Name

First NameLast Name
Email
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Phone Number
Please enter a valid phone number.
Instructions

Rate each of the following symptoms based on your health for the past thirty days. Please be totally honest, this is you health! Enter one of the following numbers next to each symptom. 0 - Never or almost never have the symptom 1 - Occasionally has it, effect is NOT severe 2 - Occasionally has it, effect IS severe 3 - Frequently has it, effect is NOT severe 4 - Frequently has it, effect IS severe
Digestive

Rate each of the following symptoms based on your health for the past thirty days. from 0 to 4
Nausea or Vomiting

0

1

2

3

4

0 is Worst, 4 is Best
Diarrhea

0

1

2

3

4

0 is Worst, 4 is Best
Constipation

0

1

2

3

4

0 is Worst, 4 is Best
Bloated feeling

0

1

2

3

4

0 is Worst, 4 is Best
Belching, passing gas

0

1

2

3

4

0 is Worst, 4 is Best
Heartburn

0

1

2

3

4

0 is Worst, 4 is Best
Energy/Activity

Rate each of the following symptoms from 0 to 4
Fatigue, sluggishness

0

1

2

3

4

0 is Worst, 4 is Best
Apathy

0

1

2

3

4

0 is Worst, 4 is Best
Hyperactivity

0

1

2

3

4

0 is Worst, 4 is Best
Restlessness

0

1

2

3

4

0 is Worst, 4 is Best
Joints/Muscles

Rate each of the following symptoms from 0 to 4
Pain or aches in joints

0

1

2

3

4

0 is Worst, 4 is Best
Arthritis

0

1

2

3

4

0 is Worst, 4 is Best
Stiff, limited movement

0

1

2

3

4

0 is Worst, 4 is Best
Pains and aches in muscles

0

1

2

3

4

0 is Worst, 4 is Best
Weakness or tiredness

0

1

2

3

4

0 is Worst, 4 is Best
Mental Health/Emotions

Rate each of the following symptoms from 0 to 4
Mood swings

0

1

2

3

4

0 is Worst, 4 is Best
Anxiety, fear, nervous

0

1

2

3

4

0 is Worst, 4 is Best
Anger, irritability

0

1

2

3

4

0 is Worst, 4 is Best
Depression

0

1

2

3

4

0 is Worst, 4 is Best
Head

Rate each of the following symptoms from 0 to 4
Headaches

0

1

2

3

4

0 is Worst, 4 is Best
Faintness

0

1

2

3

4

0 is Worst, 4 is Best
Dizziness

0

1

2

3

4

0 is Worst, 4 is Best
Insomnia

0

1

2

3

4

0 is Worst, 4 is Best
Nose

Rate each of the following symptoms from 0 to 4
Stuffy Nose

0

1

2

3

4

0 is Worst, 4 is Best
Sinus Issues

0

1

2

3

4

0 is Worst, 4 is Best
Hay fever, allergies

0

1

2

3

4

0 is Worst, 4 is Best
Sneezing attacks

0

1

2

3

4

0 is Worst, 4 is Best
Excessive Mucus

0

1

2

3

4

0 is Worst, 4 is Best
Eyes

Rate each of the following symptoms from 0 to 4
Watery, itchy eyes

0

1

2

3

4

0 is Worst, 4 is Best
Swollen, reddened, sticky eyelids

0

1

2

3

4

0 is Worst, 4 is Best
Dark circles under eyes

0

1

2

3

4

0 is Worst, 4 is Best
Blurred, tunnel vision

0

1

2

3

4

0 is Worst, 4 is Best
Ears

Rate each of the following symptoms from 0 to 4
Itchy ears

0

1

2

3

4

0 is Worst, 4 is Best
Earaches, ear infections

0

1

2

3

4

0 is Worst, 4 is Best
Drainage from ears

0

1

2

3

4

0 is Worst, 4 is Best
Ringing in ears, hearing loss

0

1

2

3

4

0 is Worst, 4 is Best
Heart

Rate each of the following symptoms from 0 to 4
Skipped heartbeats

0

1

2

3

4

0 is Worst, 4 is Best
Rapid heartbeats

0

1

2

3

4

0 is Worst, 4 is Best
Chest Pain

0

1

2

3

4

0 is Worst, 4 is Best
Lungs

Rate each of the following symptoms from 0 to 4
Chest congestion

0

1

2

3

4

0 is Worst, 4 is Best
Asthma, bronchitis

0

1

2

3

4

0 is Worst, 4 is Best
Shortness of breath

0

1

2

3

4

0 is Worst, 4 is Best
Difficulty breathing

0

1

2

3

4

0 is Worst, 4 is Best
Mouth/Throat

Rate each of the following symptoms from 0 to 4
Chronic coughing

0

1

2

3

4

0 is Worst, 4 is Best
Gagging, need to clear throat

0

1

2

3

4

0 is Worst, 4 is Best
Sore throat, hoarse

0

1

2

3

4

0 is Worst, 4 is Best
Swollen or discoloured tongue, gums or lips

0

1

2

3

4

0 is Worst, 4 is Best
Canker sores

0

1

2

3

4

0 is Worst, 4 is Best
Weight

Rate each of the following symptoms from 0 to 4
Binge eating/drinking

0

1

2

3

4

0 is Worst, 4 is Best
Craving certain foods

0

1

2

3

4

0 is Worst, 4 is Best
Excessive weight gain

0

1

2

3

4

0 is Worst, 4 is Best
Compulsive eating

0

1

2

3

4

0 is Worst, 4 is Best
Water retention

0

1

2

3

4

0 is Worst, 4 is Best
Underweight

0

1

2

3

4

0 is Worst, 4 is Best
Mind

Rate each of the following symptoms from 0 to 4
Poor memory

0

1

2

3

4

0 is Worst, 4 is Best
Confusion

0

1

2

3

4

0 is Worst, 4 is Best
Poor Concentration

0

1

2

3

4

0 is Worst, 4 is Best
Poor Coordination

0

1

2

3

4

0 is Worst, 4 is Best
Difficulty making decisions

0

1

2

3

4

0 is Worst, 4 is Best
Stuttering, stammering

0

1

2

3

4

0 is Worst, 4 is Best
Slurred speech

0

1

2

3

4

0 is Worst, 4 is Best
Learning disabilities

0

1

2

3

4

0 is Worst, 4 is Best
Skin

Rate each of the following symptoms from 0 to 4
Acne

0

1

2

3

4

0 is Worst, 4 is Best
Hives, rashes, dry skin

0

1

2

3

4

0 is Worst, 4 is Best
Hair loss

0

1

2

3

4

0 is Worst, 4 is Best
Flushion, hot flashes

0

1

2

3

4

0 is Worst, 4 is Best
Excessive sweating

0

1

2

3

4

0 is Worst, 4 is Best
Other

Rate each of the following symptoms from 0 to 4
Frequent illness

0

1

2

3

4

0 is Worst, 4 is Best
Frequent, urgent urination

0

1

2

3

4

0 is Worst, 4 is Best
Genital itch, discharge

0

1

2

3

4

0 is Worst, 4 is Best
Should be Empty:

Metabolic Recharge Symptom Survey

Instructions

Digestive

Energy/Activity

Joints/Muscles

Mental Health/Emotions

Head

Nose

Eyes

Ears

Heart

Lungs

Mouth/Throat

Weight

Mind

Skin

Other