Bio-inflammation Symptoms Questionnaire

Digestive:
___ Nausea or vomiting
___ Diarrhea
___ Constipation
___ Bloated feeling
___ Belching, passing gas
___ Heartburn

_____ TOTAL

Emotions:
___ Mood swings
___ Anxiety, fear, nervous
___ Anger, irritability
___ Depression

_____TOTAL

Eyes:
___Water, itchy eyes
___ Swollen, reddened or sticky
___ Dark circles under eyes
___ Blurred/tunnel vision

_____TOTAL

Lungs:
___ Chest congestion
___ Asthma, bronchitis
___ Shortness of breath
___ Difficulty breathing

_____TOTAL

Ears:
___ Itchy ears
___ Earaches, ear infection
___ Drainage from ear
___ Ringing in ears, hearing loss

_____TOTAL

Energy/Activity:
___ Fatigue, sluggishness
___ Apathy, sluggishness
___ Hyperactivity
___ Restlessness

_____ TOTAL

Head:
___ Headaches
___ Faintness
___ Dizziness
___ Insomnia

_____TOTAL

Mind:
___ Poor memory
___ Confusion
___ Poor concentration
___ Poor coordination
___ Difficulty making decisions
___ Stuttering, stammering
___ Learning disabilities

_____TOTAL

Mouth/Throat:
___ Chronic coughing
___ Gagging, need to clear throat
___ Sore throat, hoarse
___ Swollen, or discolored tongue, gums, lips
___ Canker Sores

_____TOTAL

Skin:
___ Acne
___ Hives, rashes, dry skin
___ Hair loss
___ Flushing or hot flashes
___ Excessive sweating

_____TOTAL

Joint/Muscles:
___ Pain or aches in joints
___ Arthritis
___ Stiff, limited movements
___ Pain, aches in muscles
___ Weakness or tiredness

_____ TOTAL

Nose:
___ Stuffy nose
___ Sinus problems
___ Hay fever
___ Excessive mucus

_____ TOTAL 

Heart:
___ Skipped heartbeats 
___ Rapid heartbeats
___ Chest pain

_____TOTAL

Weight:
___ Binge eating/drinking
___ Rapid heartbeats
___ Chest pain
___ Excessive weight gain
___ Compulsive eating
___ Water retention
___ Underweight

_____TOTAL

Other:
___ Frequent illness
___ Frequent/urgent urination
___ Genital itch, discharge

_____TOTAL

GRAND TOTAL: ___________