Symptom Check List

Date ________________________

Complete this evaluation form immediately.  It is important to have an accurate record of where you began in order to see the changes in your health over time.  Remember to update your symptom score sheet every two weeks.  Put a 1, 2, 3 or 4 beside each item that describes your symptoms, using 1 for rare and 4 for constant

SYMPTOM

  • Allergies/Hay fever
  • Bloated Feeling
  • Blood Sugar Problems
  • Body Odor
  • Bowel Gas
  • Cold Hands and Feet
  • Constipation/Diarrhea
  • Cuts and Bruises Heal Slowly
  • Dental Problems
  • Difficulty Getting Up in the Morning
  • Difficulty Falling Asleep
  • Drink Coffee/Tea/Pop
  • Eye Problems – glasses, night vision, etc
  • Feel Stressed Out
  • Food Cravings
  • Foot Pains
  • Frequent Colds and Infections
  • Frequently Take Pain Killers
  • Fuzzy Thinking/Brain Fog
  • Headaches/Migraines
  • Heartburn/Indigestion
  • Hemorrhoids
  • High/Low Blood Pressure
  • Joint Pain
  • Infections
  • Low Energy/Often Feel Tired
  • Menstrual Cramps/Moody/PMS
  • Moods of Depression/Anxiety
  • Multiple Chemical Sensitivity
  • Muscle Cramps
  • Night Sweats
  • On Medication/Drugs
  • Poor Concentration
  • Shortness of Breath
  • Skin Problems – Dry Itchy, Acne
  • Varicose Veins
  • Weak Bladder, Incontinence
  • Weak Fingernails/Unhealthy hair
  • Other ___________________________

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