Symptoms Checklist

Date

Name

First

Last

Mobile Phone

This form contains a list of health symptoms. In order for us to understand better what you are currently experiencing, please rate each symptom based on your typical health for the past month.

POINT SCALE:

0 — Never or almost never occurs

1 — Occasionally occurs, effect is not severe

2 — Occasionally occurs, effect is severe

3 — Frequently occurs, effect is not severe

4 — Frequently occurs, effect is severe

HEAD

MOUTH/THROAT

EYES

SKIN

EARS

HEART

NOSE

LUNGS

DIGESTIVE TRACT

MIND

JOINTS/MUSCLES

EMOTIONS

WEIGHT

ENERGY/ACTIVITY

OTHER

Please list any other symptoms you may be experiencing that have not been covered on this form. Please list the severity of each on a scale of 1-4:

If desired, please provide clarification or additional information on any symptoms you have marked above:

If you are human, leave this field blank.