Symptom Review Questionnaire
Hospital Logo
This review will assist you in tracking the changes your body makes physically, mentally and emotionally. Changes will be in response to your choices in diet, levels of stress, dietary supplements, exercise, relaxation or other patterns / habits that may move you towards/ away from wellness.
For each question CIRCLE the number that best applies to your experience with that symptom over the past 3 months.
0 - Never or rarely – It is rare to experience this symptom and if you do, you know what you did to trigger the reaction.
1 - Occasionally – Once in awhile you may experience this – maybe once or twice a month.
2 - Often – You experience this 1-2 times a week, enough that it bothers you.
3 - Regularly – You are constantly aware of this as it occurs almost every day or on a monthly or cyclical basis.
