0 = Never or Almost Never have the symptom

1 = Occasionally have the symptom, effect is not severe

2 = Occasionally have the symptom, effect is severe

3 = Frequently have the symptom, effect is not severe

4 = Frequently have the symptom, effect is severe

Digestive System

_____ Nausea or vomiting

_____ Diarrhea

_____ Constipation

_____ Bloated feeling

_____ Belching or passing gas

_____ Heartburn

_____ TOTAL

Ears

_____ Itchy Ears

_____ Earaches, ear infections

_____ Drainage from ear

_____ Ringing in ears, hearing loss

_____ TOTAL

Emotions

_____ Mood swings

_____ Anxiety, fear, or nervousness

_____ Anger, irritability

_____ Depression

_____ TOTAL

Lungs

_____ Chest congestion

_____ Asthma, bronchitis

_____ Shortness of breath

_____ Difficulty breathing

_____ TOTAL

Heart

_____ Irregular or skipped heartbeat

_____ Rapid or pounding heartbeat

_____ Chest pain

_____ TOTAL

Joints/Muscles

_____ Pain or aches in joints

_____ Arthritis

_____ Stiffness or limitation of movement

_____ Pain or aches in muscles

_____ Feeling of weakness or tiredness

_____ TOTAL

Energy/Activity

_____ Mood swings

_____ Anxiety, fear, nervousness

_____ Hyperactivity

_____ Restlessness

_____ Mood swings

_____ Anxiety, fear, or nervousness

_____ Anger, irritability, or aggressiveness

_____ Depression

_____ TOTAL

Eyes

_____ Watery or itchy eyes

_____ Swollen, reddened, or sticky eyelids

_____ Bags or dark circles under eyes

_____ Blurred or tunnel vision (excluding near- or farsightedness)

_____ TOTAL

Head

_____ Headaches

_____ Faintness

_____ Dizziness

_____ Insomnia

_____ TOTAL

Mind

_____ Poor memory

_____ Confusion, poor comprehension

_____ Poor physical condition

_____ Difficulty making decisions

_____ Stuttering or stammering

_____ Slurred speech

_____ Learning disabilities

_____ TOTAL

Skin

_____ Acne

_____ Hives, rashes, or dry skin

_____ Hair loss

_____ Flushing or hot flashes

_____ Excessive sweating

_____ TOTAL

Mouth/Throat

_____ Chronic coughing

_____ Gagging, frequent need to clear throat

_____ Sore throat, hoarseness, loss of voice

_____ Swollen or discolored tongue, gums, lips

_____ Canker sores

_____ TOTAL

Nose

_____ Stuffy nose

_____ Sinus problems

_____ Hay fever

_____ Sneezing attacks

_____ Excessive mucus formation

_____ TOTAL

Weight

_____ Binge eating/drinking

_____ Craving certain foods

_____ Excessive weight

_____ Compulsive eating

_____ Water retention

_____ Underweight

_____ TOTAL

Other

_____ Frequent illness

_____ Frequent or urgent urination

_____ Genital itch or discharge

_____ TOTAL

Add up the numbers in each section to get a total for each section, and then add the totals for each section to you're your grand total.

Grand Total: _________