Initial Symptom Survey

Practitioner: Courtney Rinehold RDN, CLT
Name(Required)

INSTRUCTIONS: Score every symptom based on your experience OVER THE PAST MONTH. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score to the left of EVERY symptom listed. Enter the “Grand Total” at the end. Also note the number of missed work days you have had in the last month due to illness.

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

1=OCCASIONALLY (less than 2 times per week) and symptom was MILD
2=FREQUENTLY (2 or more times per week) and symptom was MILD
3=OCCASIONALLY (less than 2 times per week) and symptom was SEVERE
4=FREQUENTLY (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