Point Scale

0 - Never or almost never have the symptom

1 - Occasionally have it, effect is not severe

2 - Occasionally have it, effect is severe

3 - Frequently have it, effect is not severe

4 - Frequently have it, effect is severe

HEAD

TOTAL __________

EYES

(does not include near or far sightedness)

TOTAL __________

EARS

TOTAL __________

NOSE

TOTAL __________

MOUTH/THROAT

TOTAL __________

SKIN

TOTAL __________

HEART

TOTAL __________

LUNGS

TOTAL __________

DIGESTIVE TRACT

TOTAL __________

JOINTS/MUSCLES

TOTAL __________

WEIGHT

TOTAL __________

ENERGY / ACTIVITY

TOTAL __________

MIND

TOTAL __________

EMOTIONS

TOTAL __________

OTHER

TOTAL __________

GRAND TOTAL __________

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