Checklist of symptoms

Name

Email

example@example.com

Please describe the main symptom/problem that you seek relief from and mark carefully those factors which can either increase or worsen your main problem/symptoms.

Since your symptoms began, have you felt an unusual desire to go outdoors or to have a window or door open to the outside or open air?

Rows	increased	decreased
Desire for open air

Please mark carefully the effect of the temperatures on your current problems?

Rows	improves	worsens	no effect
Open air
Room [closed place]
Damp weather [high humidity]
Dry weather
Cold air [Exposure to cold air like from AC or outdoors]
Dry air/weather
Wet cold air/weather

Please mark carefully the effect of the temperatures on your current problems?

Rows	improves	worsens	no effect
Cold in general [being in cool place]
Cold when getting cold [cooling of the body]
Warmth in general [being in warm place]
Covering up [putting on blanket]
Wet compress [wet cloth or compress]
Getting wet [in rain shower bath etc]

Please mark the position in which your current symptoms improve or worsen?

Rows	improves	worsens	no effect
Lying position
Lying back
Lying right side
Lying left side
Lying painful side
Lying pain free or painless side

Please mark the position in which your current symptoms improve or worsen?

Rows	improves	worsens	no effect
Sitting
Sitting bent
Standing
Lying after [as soon as head touches pillow]
Rising from bed [right after standing up]
Rising from seat [right after standing up from sitting]
Hang down, letting arm/legs hang

Movement - When your symptoms are at their worst, you feel compelled to be more sedentary/sitting or markedly more active?

Rows	desire	aversion	no effect
Movement

Movement

Rows	improves	worsens	no effect
Resting [not moving]
Movement [yoga/exercises/dancing/swimming]
Moving affected part
Walking
Running/ jogging
Physical exertion like lifting heavy objects [also includes laughing; crying; screaming]
Raising affected part [arms legs fingers]
Stretching affected part [arms legs fingers]
Bending over [like to pick up something]
Stepping hard [jarring motions; going down stairs improve or worsen or have no effect]

Movement

Rows	improves	worsens	no effect
Sitting while [act of sitting from standing]
Rising from bed while [act of getting up from lying to standing]
Rising from seat while [act of getting up from sitting to standing]
Writing [use of hands like typing, keyboard, writing]
Travelling or bouncing in car

Perception

Rows	improves	worsens	no effect
Light - When you are exposed to bright light like sunlight flash /strobe/fluorescent do you find light too strong? Do you squint, cover or shade your eyes, put on sunglasses?
Looking at screen
Reading
Touch
Pressure
Rubbing

Head

Rows	improves	worsens	no effect
Covering head warmly
Shaking head
Sneezing [if sneezing is marked or too many sneezes]
Teething while in children
Talking
Mental effort - difficult to concentrate on something

Eating drinking

Rows	improves	worsens	no effect
Swallowing
Chewing [opening closing mouth]
Before eating
While eating
After eating
Fasting
After breakfast
Cold food and drinks
Warm food and drinks

Eating drinking

Rows	improves	worsens	no effect
While drinking
After drinking
Alcohol [beer wine liquor]
Coffee
Milk [dairy/ milk products]

Hunger thirst salivation breathing

Rows	increased	decreased	no effect
Hunger [only if changed during illness]
Thirst [only if changed during illness]
Salivation [only if changed during illness]
Breathing rate

Respiration

Rows	improves	worsens
Breathing in [difficult to inhale]
Breathing out [difficult to exhale]

Pulse

Rows	fast	slow
Pulse [normal - adults 60-100. child 80-100]

Digestion

Rows	improves	worsens	no effect
Burping
Before stool
During stool
After stool
After discharge of flatus

Menstrual cycle - Since the onset of sickness have the menses been scanty/heavy/late/early/ bleeding less than 4 days or more than 4 days

Urination - Is the quantity of urine that you are excreted is more or less than what is usual for you? Do find yourself having to urinate more or less often than what is usual for you?

Sexual drive

Rows	increased	decreased	no effect
Sexual instinct

Sleep

Rows	improves	worsens	no effect
While falling asleep [difficulty to sleep due to symptoms]
During sleep/ in sleep [symptoms disturb sleep]
Waking up/ morning on opening eyes

Any other symptoms or comments

Final Checklist of symptoms