Symptoms Survey

Symptom Survey

Thank 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

Nasal/Sinus

Musculoskeletal

Emotional/Mental

Mouth/Throat

Digestive

Head/Ears

Lungs

Skin

Eyes

Weight Management

Cardiovascular

Genitourinary