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Symptom Checklist
Check the number that applies to you. If a symptom doesn't apply, leave it blank. Check MILD (occurs once or twice a month), MODERATE (occurs weekly), SEVERE (occurs daily).
Name
First
Last
Email
Date Time
MM
/
DD
/
YYYY
Section 1
Muscle weakness
MILD
MODERATE
SEVERE
Lack of stamina/fatigue easily
MILD
MODERATE
SEVERE
Muscular soreness (not caused by activity)
MILD
MODERATE
SEVERE
Racing heart
MILD
MODERATE
SEVERE
Feeling like there is a tight band around your head
MILD
MODERATE
SEVERE
Crave sweets and/or carbohydrates
MILD
MODERATE
SEVERE
Muscle spasms
MILD
MODERATE
SEVERE
Sensitivity to noise
MILD
MODERATE
SEVERE
Apprehension (feeling that something bad is going to happen)
MILD
MODERATE
SEVERE
Nervousness/Anxiety
MILD
MODERATE
SEVERE
Section 2
Eat when nervous
MILD
MODERATE
SEVERE
Eat too much, too often
MILD
MODERATE
SEVERE
Hungry between meals
MILD
MODERATE
SEVERE
Get "hangry" before meals
MILD
MODERATE
SEVERE
Get shaky when hungry
MILD
MODERATE
SEVERE
Awaken in the middle of the night. Need a snack to get back to sleep
MILD
MODERATE
SEVERE
Crave candy or coffee in the afternoon
MILD
MODERATE
SEVERE
Experience afternoon headaches
MILD
MODERATE
SEVERE
Section 3
Meat is unappealing
MILD
MODERATE
SEVERE
Get gassy a couple of hours after eating
MILD
MODERATE
SEVERE
Burning sensation when stomach is empty
MILD
MODERATE
SEVERE
Tongue has white coat after waking
MILD
MODERATE
SEVERE
Gas passed and/or stool is foul smelling
MILD
MODERATE
SEVERE
Experience sour stomach 30 minutes to 2 hours after eating
MILD
MODERATE
SEVERE
Diarrhea or loose stools after eating certain foods
MILD
MODERATE
SEVERE
Alternate between constipation and diarrhea
MILD
MODERATE
SEVERE
Section 4
Experience burning and/or itchy feet
MILD
MODERATE
SEVERE
Skin is itchy
MILD
MODERATE
SEVERE
Skin tends to be rashy for unknown reasons
MILD
MODERATE
SEVERE
Bitter or metallic taste in the mouth upon waking
MILD
MODERATE
SEVERE
Worrier (always in the past or present)
MILD
MODERATE
SEVERE
Greasy foods upset stomach
MILD
MODERATE
SEVERE
Notice peeling on the soles of feet
MILD
MODERATE
SEVERE
Stools are light colored
MILD
MODERATE
SEVERE
Discomfort or pain between shoulder blades
MILD
MODERATE
SEVERE
Pain or tenderness below or along the lower right rib
MILD
MODERATE
SEVERE
Never feeling rested upon waking, even after 8 hours of sleep
MILD
MODERATE
SEVERE
Tongue appears creviced, red and raw
MILD
MODERATE
SEVERE
Section 5
Feeling as if you are constantly racing from task to task
MILD
MODERATE
SEVERE
Upon bedtime, having a feeling of tired, yet wired
MILD
MODERATE
SEVERE
Difficulty falling asleep, mind races with circular thoughts
MILD
MODERATE
SEVERE
Anger quickly, experience irritable outbursts that are uncharacteristic
MILD
MODERATE
SEVERE
Increased weight around the waistline in the past year, with no change in eating habits.
MILD
MODERATE
SEVERE
Rapid heartbeat or racing heart
MILD
MODERATE
SEVERE
Stiffness in joints, slow recovery from injuries, or physical activity
MILD
MODERATE
SEVERE
Crave salt or salty snacks
MILD
MODERATE
SEVERE
Respiratory sensitivites such as asthma, allergies, lung infections
MILD
MODERATE
SEVERE
Excessive fatigue
MILD
MODERATE
SEVERE
Low blood pressure
MILD
MODERATE
SEVERE
Feel dizzy when rising quickly from a seated or lying position
MILD
MODERATE
SEVERE
Section 6
Hair loss on the outer third of your eyebrows
MILD
MODERATE
SEVERE
Hair course and tangled, noticeable increase in hair loss after washing, brushing
MILD
MODERATE
SEVERE
Dry or scaly skin
MILD
MODERATE
SEVERE
Increase in weight, especially around the middle
MILD
MODERATE
SEVERE
Constipation
MILD
MODERATE
SEVERE
Heavy periods
MILD
MODERATE
SEVERE
Cold hands & feet
MILD
MODERATE
SEVERE
Sensitivity to cold. You need a sweater, when others do not.
MILD
MODERATE
SEVERE
Slower speech, hoarse voice
MILD
MODERATE
SEVERE
Ringing in ears, sounds may appear diminished.
MILD
MODERATE
SEVERE
Slow heart rate or pulse (65 bpm or under) and you are not training for marathon.
MILD
MODERATE
SEVERE
Section 7 - WOMEN ONLY
Bloating, puffiness or water retention
MILD
MODERATE
SEVERE
Heavy periods or postmenopausal bleeding.
MILD
MODERATE
SEVERE
Rapid weight gain, especially in hips/butt
MILD
MODERATE
SEVERE
Fibroids
MILD
MODERATE
SEVERE
Moody: weepy, depressed, irritable
MILD
MODERATE
SEVERE
Forgetfulness (walk in a room and can't remember why).
MILD
MODERATE
SEVERE
Night sweats or hot flashes
MILD
MODERATE
SEVERE
Trouble sleeping or night waking.
MILD
MODERATE
SEVERE
Bone loss
MILD
MODERATE
SEVERE
Overall dryness: eyes, skin, vaginal
MILD
MODERATE
SEVERE
Section 8 - WOMEN ONLY
Cyclical headaches
MILD
MODERATE
SEVERE
Painful/swollen breasts
MILD
MODERATE
SEVERE
Irregular menstrual cycles, becoming more frequent, sometimes 2x per month
MILD
MODERATE
SEVERE
Easily disrupted sleep, wake up in the middle of the night.
MILD
MODERATE
SEVERE
Itchy or restless legs, worse at night.
MILD
MODERATE
SEVERE
Heavy, painful periods
MILD
MODERATE
SEVERE
Fertility challenges (6-12 months to conceive)
MILD
MODERATE
SEVERE
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