Name:
Date of Birth
Headaches
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Dizziness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Faintness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Insomnia
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Itchy/Watery Eyes
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Swollen / Red / Sticky Eyelids
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Dark Circles / Bags Under Eyes
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Blurred / Tunnel Vision
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Earaches / Ear Infections
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Itchy Ears
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Ear Drainage
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Hearing Loss / Ringing in Ears
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Stuffy Nose
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Sinus Problems
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Hay Fever
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Sneezing Attacks
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Excessive Mucous Formation
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Frequent Throat Clearing / Gagging
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Sore Throat / Hoarseness / Loss of Voice
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Swollen / Discolored Tongue, Gums, Lips
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Canker Sores
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Acne
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Hives / Rashes / Dry Skin
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Hair Loss
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Flushing / Hot Flashes
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Excessive Sweating
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Irregular / Skipped Heartbeat
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Rapid / Pounding Heartbeat
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Chest Pain
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Chest Congestion
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Chronic Coughing
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Asthma / Bronchitis
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Shortness of Breath
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Difficulty Breathing
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Nausea / Vomiting
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Diarrhea
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Constipation
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Bloated Feeling
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Belching / Passing Gas
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Heartburn
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Intestinal / Stomach Pain
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Arthritis
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Joint Pain / Aches
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Muscle Pain / Aches
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Stiff / Limited Movement
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Feeling Weak / Tired
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Binge Eating / Drinking
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Compulsive Eating / Drinking
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Water Retention
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Excessive Weight
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Under Weight
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Fatigue / Sluggishness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Apathy / Lethargy
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Hyperactivity
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Restlessness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Poor Memory
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Poor Concentration
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Confusion / Poor Comprehension
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Difficulty Making Decisions
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Learning Disability
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Poor Physical Coordination
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Stuttering / Stammering
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Slurred Speech
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Mood Swings
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Anxiety / Fear / Nervousness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Anger / Irritability / Aggressiveness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Depression
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Decreased Sex Drive
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Poor Genital Sensation
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Difficulty / Inability Having Orgasm
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Difficulty with Erection
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Difficulty with Ejaculation
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Vaginal Dryness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Frequent / Urgent Urination
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Genital Itch / Discharge
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Frequent Illness
0 = Never or Almost Never Have Symptom 1 = Occasionally Have Symptom (Not Severe) 2 = Occasionally Have Symptom (Severe) 3 = Frequently Have Symptom (Not Severe) 4 = Frequently Have Symptom (Severe)
Total Score
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