Symptom Survey

 

I look forward to speaking with you!

Please complete the following symptom survey. It will only take a couple of minutes and it will help me narrow in on your unique needs during our call.

Thank you!

  • Please rate the intensity and frequency of your symptoms using the scale of symptom points listed below. Score every symptom based on your average experience weekly over the last month.

    0 = NEVER or RARELY have this symptom.
    1 = Was MILD and OCCASIONAL (1 time per week or less)
    2 = Was MILD and FREQUENT (2 or more times per week)
    3 = Was SEVERE and OCCASIONAL (1 time per week or less)
    4 = Was SEVERE and FREQUENT (2 or more times per week)

  • CONSTITUTIONAL

  • EMOTIONAL/MENTAL

  • NEUROLOGICAL

  • SKIN

  • GENITOURINARY

  • NASAL/SINUS

  • MOUTH/THROAT

  • LUNGS

  • EYES

  • EARS

  • MUSCULOSKELETAL

  • CARDIOVASCULAR

  • DIGESTIVE

  • WEIGHT MANAGEMENT

  • OTHER SYMPTOMS

  • TOTAL

  • This field is for validation purposes and should be left unchanged.

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