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Symptom Check-In · Past Two Weeks

Medical symptoms questionnaire.

Think about the past two weeks. For each symptom, pick the rating that best describes how often you've had it and how much it bothered you. Lower totals over time mean things are moving in the right direction.

Scale

0Never
1Occasionally, mild
2Occasionally, severe
3Frequently, mild
4Frequently, severe

Head

Section total · 0
Headaches
Faintness
Dizziness
Trouble sleeping

Eyes

Section total · 0
Watery or itchy eyes
Swollen, red or sticky lids
Dark circles or bags
Blurred vision (not glasses/contacts)

Ears

Section total · 0
Itchy ears
Earaches or infections
Drainage from the ear
Ringing or hearing changes

Nose

Section total · 0
Stuffy nose
Sinus problems
Hay fever
Sneezing fits
Excess mucus

Mouth & Throat

Section total · 0
Chronic cough
Frequent throat-clearing
Sore throat or hoarseness
Swollen or discolored tongue/gums
Canker sores

Skin

Section total · 0
Acne
Rashes, hives or dry skin
Hair thinning or loss
Flushing or hot flashes
Excessive sweating

Heart

Section total · 0
Skipped or irregular beats
Racing or pounding heart
Chest discomfort

Lungs

Section total · 0
Chest congestion
Asthma or bronchitis
Shortness of breath
Difficulty breathing

Digestion

Section total · 0
Nausea
Diarrhea
Constipation
Bloating
Gas or belching
Heartburn
Stomach pain

Joints & Muscles

Section total · 0
Joint pain or aches
Stiffness or limited movement
Muscle aches or pain
Weakness or fatigue

Weight

Section total · 0
Binge eating
Cravings for certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Energy / Activity

Section total · 0
Fatigue or sluggishness
Apathy or lethargy
Hyperactivity
Restlessness

Mind

Section total · 0
Poor memory
Confusion
Poor concentration
Poor coordination
Difficulty making decisions
Stuttering / stammering
Slurred speech
Learning difficulties

Emotions

Section total · 0
Mood swings
Anxiety / nervousness
Anger / irritability
Depression

Other

Section total · 0
Frequent illness
Frequent or urgent urination
Genital itch / discharge
Grand total0

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