Self Assessment Assessment Number (REQUIRED!)* Date:* Name:*FirstLast E-mail:*Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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)_______________________________________________________________NOTE: If you have trouble dragging the bar, CLICK in space where you want the number. (It's easier!).The number you chose will be in the CENTER. Abdominal Bloating005 Achy or tense muscles005 Anxiety, tension, apprehension005 Asthma005 Audible breathing in sleep005 Bedwetting005 Belching / flatulence005 Blocked nose005 Chemical sensitivities005 Chest pains unrelated to heart005 Chest tightness005 Chest wall sore to touch005 Chronic exhaustion / physical exhaustion005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Clamminess005 Cold hands or feet005 Colic005 Confusion005 Coughing005 Depression005 Difficulty swallowing005 Disturbance of consciousness / delirium005 Dry mouth005 Easily tired005 Excessive sweating005 Exercise intolerant / lack of stamina005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Falling asleep sitting/reading/watching TV/in a car005 Fast or heavy breathing005 Fear of sultry air005 Fear without reason005 Feelings of unreality005 Food allergies005 Frequent or urgent urination005 Frightening / intense dreams005 General tiredness or weakness005 Generalized weakness or 'weak at the knees'005 Grinding teeth005 Hay Fever, sneezing005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Headache005 Heartburn005 Inability to take a deep breath005 Increased thirst005 Insomnia005 Irregular, pounding or racing heartbeat005 Irritability005 Irritable bowel, constipation or diarrhea005 Light-headed or dizzy005 Loss of sense of smell005 Lung congestion or bronchitis005 Many cavities005 Mental fatigue005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Mouth breathing in sleep005 Mouth breathing when awake005 Mucus congestion005 Muscle spasms/ tremors/ twitching005 Muscle tension, spasms or cramping005 Muscle weakness005 Nasal/sinus congestion on waking005 Numbness or tingling hands, feet, face005 Pains in bones or joints005 Panic attacks005 Pollen, dust allergies005 Poor concentration / memory005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Post-nasal drip005 Prone to colds, flu, chest infection005 Restless legs005 Sense of losing your mind005 Short of breath at rest005 Short of breath on exertion005 Sighing habitually005 Sinusitis005 Sleep apnea (breath stoppages) noticed by others005 Sleepiness during day005 Snoring005 Spaced out feeling005 Throat clearing005 Tremors, twitches, tics005Please rate your symptoms:0 - Never / none1 - Very occasional / mild seasonal2 - 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) Unsteadiness or fainting005 Upper chest breathing005 Waking up tired005 Waking up with a headache005 Weight gain005 Weight loss005 Wheezing005 Yawning when not tired005 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 Please verify you are human, If you get this wrong, all your entries will seem to disappear. DO NOT WORRY! They are there. Try again to verify and when correct, then submit. THANKS FOR TAKING THE TIME TO DO THIS! It is important information for your teacher.SubmitReset