Symptoms Survey Form

[ronipow]

Emily uses this form to keep tract of her progress. I thought there might be some interest.

Roni


CONSTITUTIONAL
___ Fatigue (sluggish, tired)
__ Hyperactive (nervous energy)
___ Restless (can’t relax/sit still)
___ Sleepiness During Day
___ Insomnia at Night
____ TOTAL (0-20)
EMOTIONAL/MENTAL
___ Depression (feelings of
hopelessness)
___ Anxiety (vague fears,
uneasiness)
___ Mood Swings (rapid
distinct changes)
___ Irritability
___ Forgetfulness
__ Lack of concentration/focus
____ TOTAL (0-24)
HEAD/EARS
____ Headache (any kind)
____ Earache
____ Ear Infection
____ Ringing in Ear
____ Itchy Ears
____ Discharge From Ears
____ TOTAL (0-24)
SKIN
____ Blemishes, Acne
____ Rashes, Hives
____ Eczema
____ “Rosy” Cheeks
____ TOTAL (0-16) NASAL/SINUS
____ Post Nasal Drip
____ Sinus Pain
____ Runny Nose
____ Stuffy Nose
____ Sneezing
____ TOTAL (0-20)
MOUTH/THROAT
____ Sore Throat
____ Swollen Throat
____ Swelling of Lips/Tongue
___ Gagging/Throat Clearing
___ Lesions ("Canker Sores")
____ TOTAL (0-20)
LUNGS
____ Wheezing" (Asthma or
Asthma-like Symptoms)
____ Chest Congestion
____ Non-Productive Coughing
____ Productive Coughing
___ TOTAL (0-20)
EYES
_____ Red or Swollen Eyes
_____ Watery Eyes
_____ Itchy Eyes
_____ Dark Circles" or "Baggy"
_____ TOTAL (0-16)
GENITOURINARY
_____ Increased Urinary
Frequency
_____ Painful Urination
_____ TOTAL (0-8) MUSCULOSKELETAL
___ Joint Pains/Aching
____ Stiff Joints
___ Muscle Aches
__ Stiff Muscles
____ TOTAL (0-20)
CARDIOVASCULAR
____ Irregular Heartbeat
____ High Blood Pressure _0___ TOTAL (0-8)
DIGESTIVE
____ Heartburn/Esoph.Reflux
____ Stomach Pains/Cramps
___ Intestinal Pains/Cramps
____ Constipation
____ Diarrhea
____ Bloating Sensation
____ Gas (of Any Kind)
____ Nausea, Vomiting
____ Painful Elimination
___ TOTAL (0-36)

WEIGHT MANAGEMENT
____ Record Actual Weight
_ ___ Height
____ Fluctuating Weight
____ Food Cravings
___ Water Retention
____ Binge Eating or Drinking
____ Purging (all methods)
____ TOTAL (0-20)

Patient Name:__ _____________________________ Date:_ _______________


SYMPTOM SURVEY
Instructions: The way to fill out the form is simple. Start with the first symptom and ask yourself, "Lately, have I experienced this symptom?" If you answer no or almost not at all, then write a "0" in the corresponding field. If the answer is yes, then ask yourself if you experience the symptom occasionally (less than 2 times in a week) or frequently (2 or more times in a week). After you have decided on the frequency, then ask yourself if the symptom is "Severe" or "Not Severe". Using the SCALE OF SYMPTOM POINTS listed below, write the appropriate score in the corresponding field for EVERY symptom listed. Total the points for each category and add all category totals to come up with the Grand Total. After completion, turn in this form to your health care provider.
SCALE OF SYMPTOM POINTS:
0 = Do Not Suffer From This Ever or Almost Ever
1 = Suffer OCCASSIONALLY (less than 2 times per week), is not severe
2 = Suffer FREQUENTLY (2 or more times per week), is not severe
3 = Suffer OCCASSIONALLY and is severe
4 = Suffer FREQUENTLY and is severe _____ INITIAL REPORT (or)
_____ FOLLOW-UP (circle)

1 2 3 4 5 6 7 Grand Total:

[annie oakley]

Hi, Is this just to look at and review ? Cause I can't figure out how to mark little x's in the appropriate boxes. Looks good tho Love Herb Lady

[ronipow]

This would be for your personal use. It's a good way to keep track of your symptoms. Sometimes you may be making progress and don't really realize it.

Roni

[Arlene]

This is a great idea. Especially for those just starting out on the diet.

Much love
Arlene

[kate_ce1995]

Does she do this on a weekly basis? Other? I think I might start doing this to better track my "slip ups". I think they are based on when I'm really tired and busy. But maybe there is another pattern as well. The anti-smoking campain in my state is running adds about patters of "always needing a smoke when in certain situations". Perhaps my gluten cravings/giving in follows something similar that i can try and avoid.

Katy

[TendrTummy]

I've copied this into my journals in the journals area and am going to do one weekly on Tuesdays. FUN!!!

Christine

[ronipow]

I was hoping you would find this page. It seemed to slip down to the bottom. We were able to figure out that Emily was doing about 50% better by using this form.

Good luck guys,
Roni

[kate_ce1995]

50% is a great improvement for the length of time you've been there. kudos to both of you. keep up the good work.
Katy