Self Assessment

Rate each of the following symptoms based upon your experience in the last 30 days.


This questionnaire is a general indicator of the level of inflammation in your body based on your symptoms.

 

Generally speaking, if you scored 1-15 points, inflammation is not an area that needs your immediate attention.

 

A score of 16 - 30 means inflammation may be contributing to your symptoms and it’s a good time to focus on reducing your body burden.

 

A score of 30 and over means that chronic inflammation is most definitely present and your body needs your immediate attention!

	Point Scale: 0 = Never or Almost never have the symptom 1 = Occasionally have the symptom, effect is not severe 2 = Occasionally have the symptom, effect is severe 3 = Frequently have the symptom, effect is not severe 4 = Frequently have the symptom, effect is severe
	0	1	2	3	4		Digestive System
							Nausea or vomiting
							Diarrhea
							Constipation
							Bloated feeling
							Belching or passing gas
							Heartburn
							Ears
							Itchy ears
							Earaches, ear infections
							Drainage from ear
							Ringing in ears
							Hearing loss
							Emotions
							Mood swings
							Anxiety, fear, or nervousness
							Anger, irritability
							Depression
							Energy/Activity
							Fatigue, sluggishness
							Apathy, lethargy
							Hyperactivity
							Restlessness
							Eyes
							Watery or itchy eyes
							Swollen, reddened, or sticky eyelids
							Dark circles under eyes
							Blurred or tunnel vision
							Head
							Headaches
							Faintness
							Dizziness
							Insomnia
							Heart
							Irregular or skipped heartbeat
							Rapid heartbeat
							Chest pain
							Joints/Muscles
							Pain or aches in joints
							Arthritis
							Stiffness or limited movement
							Pain or aches in muscles
							Feeling of weakness or tiredness in joints
							Lungs
							Chest congestion
							Asthma, bronchitis
							Shortness of breath
							Difficulty breathing
							Mind
							Poor memory
							Confusion
							Poor concentration
							Poor coordination
							Difficulty making decisions
							Stuttering or stammering
							Slurred speech
							Learning disabilities
							Nose
							Stuffy nose
							Sinus problems
							Hay fever
							Sneezing attacks
							Excessive mucus formation
							Mouth-Throat
						Chronic coughing
						Gagging, frequent need to clear throat
						Sore throat, hoarseness
						Swollen or discolored tongue, gums or lips
						Canker sores
						Skin
						Acne
						Hives, rashes, or dry skin
						Hair loss
						Flushing or hot flashes
						Excessive sweating
						Weight
						Binge eating/drinking
						Craving certain foods
						Excessive weight
						Compulsive eating
						Water retention
						Underweight
						Other
						Frequent illness
						Frequent or urgent need to urinate
						Genital itch or discharge