Symptoms Survey

Symptom Survey

cm-footer-picThank you so much for taking the time to learn more about how foods can affect you.I’m Colleen and I’m a registered dietitian and intuitive health coach. I love creating possibilities for special clients who desire something more in their life to really feel life. They really appreciate that I get to know who they are as a person when we work together, and how that we can actually have fun while doing it!

I began using this survey with my private clients to understand where they are at – and they loved it so much – I wanted to be able to offer it to everyone! I would love to hear your insights and look forward to supporting you on your journey.

All my best!

Colleen

 

Instructions: The way to fill out the form is simple.  There are 13 sections, each representing a system in the body. Within each section, are related symptoms. Start with the first symptom and ask yourself, “Lately, have I experienced this symptom?” If you answer no or almost not at all, then write a “0” in the corresponding field.  If the answer is yes, then ask yourself if you experience the symptom occasionally (less than 2 times in a week) or frequently (2 or more times in a week).  After you have decided on the frequency, then ask yourself if the symptom is “Severe” or “Not Severe”. Using the SCALE OF SYMPTOM POINTS listed below, select the appropriate score in the corresponding field for EVERY symptom listed. You will receive a detailed report on your survey upon completion. 

SCALE OF SYMPTOM POINTS:
0 = Do Not Suffer From This Ever or Almost Ever
1 = Suffer OCCASSIONALLY (less than 2 times per week), is not severe
2 = Suffer FREQUENTLY (2 or more times per week), is not severe
3 = Suffer OCCASSIONALLY and is severe
4 = Suffer FREQUENTLY and is severe

Constitutional
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Fatigue (sluggish/tired)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Sleepiness During Day
Insomnia at Night
Lousy Feeling
Nasal/Sinus
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Post Nasal Drip
Sinus Pain
Stuffy Nose
Runny Nose
Sneezing
Musculoskeletal
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Joint Pains/Aching
Stiff Joints
Muscle Aches
Stiff Muscles
Emotional/Mental
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Depression (feelings of Hopelessness
Anxiety (vague fears, uneasiness
Mood Swings (rapid distinct changes)
Irritability
Forgetfulness
Lack of concentration/focus
Mouth/Throat
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Sore throat
Swollen throat
Swelling Lips/Tongue
Gagging/Throat Clearing
Lesions (“Canker Sores”)
Digestive
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Heartburn/Esoph Reflux
Stomach Pains/Cramps
Intestinal Pains/Cramps
Constipation
Diarrhea
Bloating Sensation
Gas (of Any Kind)
Nausea, Vomiting
Painful Elimination
Head/Ears
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Headache (Any kind)
Earache
Ear infection
Ringing in Ear
Itchy Ears
Lungs
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Wheezing (Asthma or Asthma-like Symptoms)
Chest Congestion
Non-Productive Coughing
Productive Coughing
Skin
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Blemishes, Acne
Rashes, Hives
Eczema
“Rosy” Cheeks
Eyes
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Red or Swollen Eyes
Watery Eyes
Itchy Eyes
“Dark Circles” or “Baggy”
Weight Management
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Fluctuating Weight
Food Cravings
Water Retention
Binge Eating or Drinking
Purging (all methods)
Cardiovascular
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Irregular Heartbeat
High Blood Pressure
Genitourinary
Symptom 0

Never/
Almost Never
1

Occasional
0-1x/wk
(non severe)
2

Frequent
2x/wk
(non severe)
3

Occasional
(severe)
4

Frequent
(severe)
Increased Urinary Frequency
Painful Urination