Self Assessment

Assessment #*
Date:*
Name:*
E-mail:*

Please rate your symptoms:

  • 0 - Never / none
  • 1 - Very occasional / mild seasonal
  • 2 - Occasional (e.g. weekly)
  • 3 - Daily or almost daily - mild/not severe (including seasonal)
  • 4 - Daily or almost daily - severe at times (including seasonal)
  • 5 - Daily and severe / continuous (including seasonal)
Abdominal Bloating
0
0
5
Achy or tense muscles
0
0
5
Anxiety, tension, apprehension
0
0
5
Asthma
0
0
5
Audible breathing in sleep
0
0
5
Bedwetting
0
0
5
Belching / flatulence
0
0
5
Blocked nose
0
0
5
Chemical sensitivities
0
0
5
Chest pains unrelated to heart
0
0
5
Chest tightness
0
0
5
Chest wall sore to touch
0
0
5
Chronic exhaustion / physical exhaustion
0
0
5
Clamminess
0
0
5
Cold hands or feet
0
0
5
Colic
0
0
5
Confusion
0
0
5
Coughing
0
0
5
Depression
0
0
5
Difficulty swallowing
0
0
5
Disturbance of consciousness / delirium
0
0
5
Dry mouth
0
0
5
Easily tired
0
0
5
Excessive sweating
0
0
5
Exercise intolerant / lack of stamina
0
0
5
Falling asleep sitting/reading/watching TV/in a car
0
0
5
Fast or heavy breathing
0
0
5
Fear of sultry air
0
0
5
Fear without reason
0
0
5
Feelings of unreality
0
0
5
Food allergies
0
0
5
Frequent or urgent urination
0
0
5
Frightening / intense dreams
0
0
5
General tiredness or weakness
0
0
5
Generalized weakness or “weak at the knees”
0
0
5
Grinding teeth
0
0
5
Hay Fever, sneezing
0
0
5
Headache
0
0
5
Heartburn
0
0
5
Inability to take a deep breath
0
0
5
Increased thirst
0
0
5
Insomnia
0
0
5
Irregular, pounding or racing heartbeat
0
0
5
Irritability
0
0
5
Irritable bowel, constipation or diarrhea
0
0
5
Light-headed or dizzy
0
0
5
Loss of sense of smell
0
0
5
Lung congestion or bronchitis
0
0
5
Many cavities
0
0
5
Mental fatigue
0
0
5
Mouth breathing in sleep
0
0
5
Mouth breathing when awake
0
0
5
Mucus congestion
0
0
5
Muscle spasms/ tremors/ twitching
0
0
5
Muscle tension, spasms or cramping
0
0
5
Muscle weakness
0
0
5
Nasal/sinus congestion on waking
0
0
5
Numbness or tingling hands, feet, face
0
0
5
Pains in bones or joints
0
0
5
Panic attacks
0
0
5
Pollen, dust allergies
0
0
5
Poor concentration / memory
0
0
5
Post-nasal drip
0
0
5
Prone to colds, flu, chest infection
0
0
5
Restless legs
0
0
5
Sense of “losing your mind”
0
0
5
Short of breath at rest
0
0
5
Short of breath on exertion
0
0
5
Sighing habitually
0
0
5
Sinusitis
0
0
5
Sleep apnea (breath stoppages) noticed by others
0
0
5
Sleepiness during day
0
0
5
Snoring
0
0
5
Spaced out feeling
0
0
5
Throat clearing
0
0
5
Tremors, twitches, tics
0
0
5
Unsteadiness or fainting
0
0
5
Upper chest breathing
0
0
5
Waking up tired
0
0
5
Waking up with a headache
0
0
5
Weight gain
0
0
5
Weight loss
0
0
5
Wheezing
0
0
5
Yawning when not tired
0
0
5
Needing and taking a day nap (Number of days per week)
Number of toilet visits per night
Number of wakings per night
Runny nose (number of tissues per day)
Wake self with gasp/snort etc – times/night
Other symptoms not listed
Verify you are human (although if you spent all that time filling out this form and you aren't, I have to wonder about you!)