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Inflammation Assessment
Inflammation Questionnaire
Rate each symptom based on your health over the past 30 days. If completing for a 2nd or 3rd time, rate symptoms from the past week only.
0 = Never1 = Occasionally, not severe2 = Occasionally, severe3 = Frequently, not severe4 = Frequently, severe
Grand Total
0
Optimal
Digestive Tract
7 symptoms · rate 0–4
0
1.Nausea or vomiting
2.Diarrhea
3.Constipation
4.Bloated feeling
5.Belching or passing gas
6.Heartburn
7.Intestinal/Stomach pain
Ears
4 symptoms · rate 0–4
0
1.Itchy ears
2.Earaches, ear infections
3.Drainage from ear
4.Ringing in ears, hearing loss
Emotions
4 symptoms · rate 0–4
0
1.Mood swings
2.Anxiety, fear or nervousness
3.Angry, irritable or aggressive
4.Depression
Energy / Activity
4 symptoms · rate 0–4
0
1.Fatigued, sluggish, tired
2.Apathy, lethargy
3.Hyperactivity
4.Restlessness
Eyes
4 symptoms · rate 0–4
0
1.Watery or itchy eyes
2.Swollen, reddened or sticky eyelids
3.Bags or dark circles under eyes
4.Blurred or tunnel vision
Head
4 symptoms · rate 0–4
0
1.Headaches
2.Faintness
3.Dizziness
4.Insomnia
Heart
3 symptoms · rate 0–4
0
1.Irregular or skipped heartbeat
2.Rapid or pounding heartbeat
3.Chest pain
Joints / Muscles
5 symptoms · rate 0–4
0
1.Pain or aches in joints
2.Arthritis
3.Stiffness or limitation of movement
4.Pain or aches in muscles
5.Feeling of weakness or tiredness
Lungs
4 symptoms · rate 0–4
0
1.Chest congestion
2.Asthma, bronchitis
3.Shortness of breath
4.Difficult breathing
Mind
8 symptoms · rate 0–4
0
1.Poor memory
2.Confusion, poor comprehension
3.Poor concentration
4.Poor physical coordination
5.Difficulty in making decisions
6.Stuttering or stammering
7.Slurred speech
8.Learning disabilities
Mouth / Throat
5 symptoms · rate 0–4
0
1.Chronic coughing
2.Gagging, frequently clearing throat
3.Sore throat, hoarseness, loss of voice
4.Swollen/discolored tongue, gum, lips
5.Canker sores
Nose
5 symptoms · rate 0–4
0
1.Stuffy nose
2.Sinus problems
3.Hay fever
4.Sneezing attacks
5.Excessive mucus formation
Skin
5 symptoms · rate 0–4
0
1.Acne
2.Hives, rashes or dry skin
3.Hair loss
4.Flushing or hot flushes
5.Excessive sweating
Weight
6 symptoms · rate 0–4
0
1.Binge eating/drinking
2.Craving certain foods
3.Excessive weight
4.Compulsive eating
5.Water retention
6.Underweight
Other
3 symptoms · rate 0–4
0
1.Frequent illness
2.Frequent or urgent urination
3.Genital itch or discharge
71 symptoms remaining