Information only; not a diagnosis. Please seek medical advice for any concerns.
Section 1: 38-Point Symptom Frequency How often if the past month have the following symptoms been experienced ? ( Rating scale :(0=Never, 1=Sometimes, 2=Most, 3=All the time. Blank=No symptoms.)
Unexplained fevers, sweats, chills, or flushing 1. Unexplained fevers, sweats, chills, or flushing 0 1 2 3 Unexplained weight change - loss or gain 2. Unexplained weight change - loss or gain 0 1 2 3 Fatigue, tiredness 3. Fatigue, tiredness 0 1 2 3 Unexplained hair loss 4. Unexplained hair loss 0 1 2 3 Swollen glands 5. Swollen glands 0 1 2 3 Sore throat 6. Sore throat 0 1 2 3 Testicular pain / Pelvic pain 7. Testicular pain / Pelvic pain 0 1 2 3 Unexplained menstrual irregularity 8. Unexplained menstrual irregularity 0 1 2 3 Unexplained breast milk production, breast pain 9. Unexplained breast milk production, breast pain 0 1 2 3 Irritable bladder or bladder dysfunction 10. Irritable bladder or bladder dysfunction 0 1 2 3 Sexual dysfunction / loss of libido 11. Sexual dysfunction / loss of libido 0 1 2 3 Upset stomach 12. Upset stomach 0 1 2 3 Change in bowel function (constipation or diarrhea) 13. Change in bowel function (constipation or diarrhea) 0 1 2 3 Chest pain or rib soreness 14. Chest pain or rib soreness 0 1 2 3 Shortness of breath / cough 15. Shortness of breath / cough 0 1 2 3 Heart palpitations, pulse skips, heart block 16. Heart palpitations, pulse skips, heart block 0 1 2 3 History of heart murmur or valve prolapse 17. History of heart murmur or valve prolapse 0 1 2 3 Joint pain or swelling 18. Joint pain or swelling 0 1 2 3 Stiffness of the neck or back 19. Stiffness of the neck or back 0 1 2 3 Muscle pain or cramps 20. Muscle pain or cramps 0 1 2 3 Twitching of the face or other muscles 21. Twitching of the face or other muscles 0 1 2 3 Headaches 22. Headaches 0 1 2 3 Neck cracks or neck stiffness 23. Neck cracks or neck stiffness 0 1 2 3 Tingling, numbness, burning, or stabbing sensations 24. Tingling, numbness, burning, or stabbing sensations 0 1 2 3 Facial paralysis (Bell’s palsy) 25. Facial paralysis (Bell’s palsy) 0 1 2 3 Eyes/vision – double, blurry 26. Eyes/vision – double, blurry 0 1 2 3 Ears/hearing – buzzing, ringing, ear pain 27. Ears/hearing – buzzing, ringing, ear pain 0 1 2 3 Increased motion sickness, vertigo 28. Increased motion sickness, vertigo 0 1 2 3 Lightheadedness, poor balance, difficulty walking 29. Lightheadedness, poor balance, difficulty walking 0 1 2 3 Tremors 30. Tremors 0 1 2 3 Confusion, difficulty thinking 31. Confusion, difficulty thinking 0 1 2 3 Difficulty with concentration or reading 32. Difficulty with concentration or reading 0 1 2 3 Forgetfulness, poor short-term memory 33. Forgetfulness, poor short-term memory 0 1 2 3 Disorientation; getting lost, going to wrong places 34. Disorientation; getting lost, going to wrong places 0 1 2 3 Difficulty with speech or writing 35. Difficulty with speech or writing 0 1 2 3 Mood swings, irritability, depression 36. Mood swings, irritability, depression 0 1 2 3 Disturbed sleep – too much, too little, early awake 37. Disturbed sleep – too much, too little, early awake 0 1 2 3 Exaggerated symptoms or worse hangover from alcohol 38. Exaggerated symptoms or worse hangover from alcohol 0 1 2 3 