Follow-up Symptom Survey

Practitioner: Courtney Rinehold RDN, CLT
Name(Required)
MM slash DD slash YYYY

INSTRUCTIONS: Using the “Scale of Symptom Points” listed to the right, score every symptom based on your experience OVER THE PAST WEEK, then subtotal each category. Add the subtotals and record the “Grand Total” at the bottom of the form.

SCALE OF SYMPTOM POINTS
IF you did not suffer from the symptom ever or almost never, leave it blank.

1=MILD & OCCASIONAL (less than 2 times per week) and symptom was MILD
2=MILD & FREQUENT (2 or more times per week) and symptom was MILD
3=SEVERE & OCCASIONAL (less than 2 times per week) and symptom was SEVERE
4=SEVERE & FREQUENT (2 or more times per week) and symptom was SEVERE

CONSTITUTIONAL

EMOTIONAL/MENTAL

HEAD/EARS

SKIN

NASAL/SINUS

MOUTH/THROAT

LUNGS

EYES

GENITOURINARY

MUSCULOSKELETAL

CARDIOVASCULAR

DIGESTIVE

Weight Management

OTHER SYMPTOMS

FINAL CALCULATIONS