Many health conditions are commonly misdiagnosed. This Symptom Questionnaire will help guide you in selecting the best medical labs to determine symptom causes.
Please keep in mind the results of the questionnaire is not a diagnosis. This can only be made by a qualified health professional. The Questionnaire is a path to quality medical care which we encourage you to bring with you to your doctor's appointment.
Instructions: Please check the appropriate box for each symptom. If you occasionally experience mild or moderate symptoms, check mild. If you continuously have moderate symptoms or occasionally have severe symptoms check severe. If you do not experience a particular symptom at all, simply do not make a selection for that symptom.
To insure your privacy, your completed questionnaire will not be saved. If you want to keep a copy of it for your records please make a screen print (Cntrl+P on most computers) before clicking SUBMIT. |
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| Cognitive Systems |
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| Fatigue |
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severe |
| Anxiety, Nervousness, Irritability |
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severe |
| Sleeping Difficulty |
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severe |
| Brain Fog |
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severe |
| Anger, Aggressive Behavior |
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severe |
| behavior or personality changes |
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severe |
| Mood Swings, Lability |
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severe |
| Apathy |
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severe |
| Hallucinations, Psychosis, Delusions |
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severe |
| Frequent Sadness, Crying |
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severe |
| Easily Distracted by Extraneous |
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severe |
| Memory Loss |
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severe |
| Impaired Concentration |
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severe |
| Alcoholism/Excessive Alcohol |
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severe |
| Sugar Cravings |
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severe |
| Hunger, Binge Eating |
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severe |
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| Immune Process |
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| Respiration- asthma, cough, shorteness of bre |
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severe |
| Frequent Yeast Infections |
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severe |
| Allergies |
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severe |
| Frequent Flu Symptoms |
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severe |
| Immunity Depressed, Frequent |
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severe |
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| Heart, Blood, Circulation |
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| Blood pressure high or low |
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severe |
| High Cholesterol |
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severe |
| Heart Palpitations, Rhythm Abnormalities |
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severe |
| Anemia |
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severe |
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| Nervous System |
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| Carpal Tunnel Syndrome |
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severe |
| Restless Leg Syndrome |
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severe |
| Numbness or Tingling in Extremities |
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severe |
| Difficulty Walking, Poor Balance |
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severe |
| Spasm, Muscle Tics, Trembling, Twitching |
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severe |
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| Senses |
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| Dizziness |
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severe |
| Vision Changes, Blurred Vision |
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severe |
| Light Sensitivity |
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severe |
| Tinnitus, Ringing, Ear Sounds |
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severe |
| Cold Sensitivity, Extremities, Low Body Temp |
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severe |
| Excessive Sweating, Night Sweats, Fevers |
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severe |
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| GI System |
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| Abdominal Pain |
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severe |
| Abdominal Swelling |
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severe |
| Colic |
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severe |
| Frequent Constipation or Diarrhea |
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severe |
| Excessive Thirst |
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severe |
| Indigestion, Heartburn, Gas |
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severe |
| Weight Gain |
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severe |
| Nausea |
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severe |
| Weight Loss or Poor Appetite |
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severe |
| Ulcers |
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severe |
| Frequent or Decreased Urination |
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severe |
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| Reproductive System |
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| Absence of Menstruation, Irregular Periods |
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severe |
| Breast Pain, Tenderness |
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severe |
| Infertility |
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severe |
| Painful Intercourse, Vaginal Dryness |
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severe |
| Hot Flashes |
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severe |
| Loss of Libido |
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severe |
| Erectile Dysfunction |
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severe |
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| Pain |
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| Migraines, Headaches |
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severe |
| Bone, Back, or Leg Pain (Skeletal) |
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severe |
| Joint Pain |
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severe |
| Muscle Pain |
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severe |
| Achiness |
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severe |
| Muscle Cramps |
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severe |
| Muscle Weakness |
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severe |
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| Skin, hair, nails |
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| Mouth Ulcers, Canker Sores, or Corners of Mou |
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severe |
| Dry Brittle Hair, Hair Loss |
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severe |
| Dry or Itchy Skin |
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severe |
| Tender or Bleeding Gum |
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severe |
| Acne, Eczema |
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severe |
| Pale Skin |
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severe |
| Skin Rash |
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severe |
| Edema, Swelling |
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severe |
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