Symptom Survey – Nourish Your Life – Sandy Kipp Registered Dietitian

Name*
First Last
INSTRUCTIONS: Score every symptom based on your experience OVER THE PAST WEEK. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score in box in front of the corresponding field for EVERY symptom listed.

SCALE OF SYMPTOM POINTS
- NA = Not Applicable
- 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*
NA 1 2 3 4
Fatigue (sluggish, tired)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Daytime sleepiness
Insomnia at night
Malaise (feeling lousy)
Seizures
EMOTIONAL/MENTAL*
NA 1 2 3 4
Depression
Anxiety (fears, uneasiness)
Mood swings (rapid changes)
Irritability
Forgetfulness
Lack of concentration/Brain fog
Low sex drive
MUSCULOSKELETAL*
NA 1 2 3 4
Joint pains
Stiff joints
Muscle aches
Stiff muscles
Ticks (facial or otherwise)
Muscle spasms
Muscle cramps
HEAD/EARS*
NA 1 2 3 4
Headache (not migraine)
Migraine
Earache
Ear infection
Ringing in ears
Itchy ears
Discharge from ears
Sensitivity to sound
SKIN*
NA 1 2 3 4
Blemishes, acne
Rashes of hives
Eczema or psoriasis
"Rosy" cheeks
Flushing
Itchy skin
EYES*
NA 1 2 3 4
Red or swollen eyes
Watery eyes
Itchy eyes
Dark circles or "bags"
Sensitivity to light
Aura
NASAL/SINUS*
NA 1 2 3 4
Post nasal drip
Sinus pain
Runny nose
Stuffy nose
Sneezing
LUNGS*
NA 1 2 3 4
Wheezing
Chest congestion
Dry cough
Wet cough
Shortness of breath
DIGESTIVE*
NA 1 2 3 4
Heartburn/reflux
Stomach pains/cramps
Intestinal pains/cramps
Constipation
Diarrhea
Bloating sensation
Gas (of any kind)
Nausea
Vomiting
Painful elimination
GENITOURINARY*
NA 1 2 3 4
Increased urinary frequency
Painful urination
Bladder pain
Bedwetting
CARDIOVASCULAR*
NA 1 2 3 4
Irregular heartbeat
High blood pressure
MOUTH/THROAT*
NA 1 2 3 4
Sore throat
Swollen throat
Swelling/burning lips/tongue
Gagging/throat clearing
Canker sores
Difficulty swallowing
WEIGHT MANAGEMENT*
NA 1 2 3 4
Fluctuating weight
Food cravings
Water rentention
Binge eating or drinking
Purging (all methods)
Current Weight
Number of missed work days in the past week due to illness*
LIST OTHER SYMPTOMS
Phone
This field is for validation purposes and should be left unchanged.

	NA	1	2	3	4
Fatigue (sluggish, tired)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Daytime sleepiness
Insomnia at night
Malaise (feeling lousy)
Seizures

	NA	1	2	3	4
Depression
Anxiety (fears, uneasiness)
Mood swings (rapid changes)
Irritability
Forgetfulness
Lack of concentration/Brain fog
Low sex drive

	NA	1	2	3	4
Joint pains
Stiff joints
Muscle aches
Stiff muscles
Ticks (facial or otherwise)
Muscle spasms
Muscle cramps

	NA	1	2	3	4
Headache (not migraine)
Migraine
Earache
Ear infection
Ringing in ears
Itchy ears
Discharge from ears
Sensitivity to sound