Questionnaire
Complete this free guided questionnaire based on the symptoms you have experienced during the past 30 days. At the end, share your contact details to receive your result and request follow-up from our team.
Important safety notice
This questionnaire is not monitored in real time and is not an emergency service. It does not provide a medical diagnosis. If you are currently experiencing chest pain, severe difficulty breathing, sudden neurological symptoms, or another medical emergency, call 911 or seek immediate medical care. If you are in emotional crisis or considering harming yourself, call or text 988. If you are outside the United States, contact your local emergency services.
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How to answer
Based on the past 30 days, rate each symptom using the scale below.
0 — Never or almost never
1 — Occasionally, mild effect
2 — Occasionally, severe effect
3 — Frequently, mild effect
4 — Frequently, severe effect
About your score
Your score summarizes the frequency and perceived impact of the symptoms you reported over the past 30 days. It is intended to support a wellness conversation with a qualified professional. It does not diagnose toxicity, disease, or any other medical condition and should not replace medical evaluation or treatment.
HEAD
Headaches
Faintness
Dizziness
Insomnia
EYES
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (not nearsightedness or farsightedness)
EARS
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
NOSE
Stuffy nose
Sinus problems
Runny nose, sneezing, watery eyes and itchy eyes (all together)
Sneezing attacks
Excessive mucus formation
MOUTH AND THROAT
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
SKIN
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
HEART
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
LUNGS
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
DIGESTIVE TRACT
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal or stomach pain
JOINTS AND MUSCLES
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
ENERGY OR ACTIVITY
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
MIND
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
EMOTIONS
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
WEIGHT
Binge eating or drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
OTHER
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total
71 questions left to answer.
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