Health Quiz

The Health Quiz is not diagnostic but serves as a baseline and progress-tracking tool.

It identifies symptoms that help to identify the underlying causes of decreased performance or illness, and helps you track your progress over time.

How to Complete

INSTRUCTIONS
* Rate each of the following symptoms based upon your health profile and symptoms for the last 48 hours ONLY using the POINT SCALE below.
* Select ONLY ONE response for each category.
* A response is required for each category to complete submission of the form.
* If you are unable to submit your quiz, please review your responses for "required" categories.
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

Name

Phone

Nausea or vomiting

Diarrhea

Constipation

Bloated feeling

Belching or passing gas

Heartburn

Intestinal/stomach pain

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Mood swings

Anxiety, fear or nervousness

Anger, irritability, or aggressiveness

Depression

Fatigue, sluggishness

Apathy, lethargy

Hyperactivity

Restlessness

Watery or itchy eyes

Swollen, reddened or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision (does not include near- or far-sightedness)

Headaches

Faintness

Dizziness

Insomnia

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Pain or aches in joints

Arthritis

Stiffness or limitation in movement

Pain or aches in muscles

Feeling of weakness or tiredness

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficult breathing

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Chronic coughing

Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen/discolored tongue, gums, lips

Canker sores

Stuffy nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

Acne

Hives, rashes, or dry skin

Hair loss

Skin flushes or hot flushes

Excessive sweating

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

Frequent illness

Frequent or urgent urination

Genital itch or discharge

I'm interested in speaking with a team member about my results for a more in-depth analysis.

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