• Click here for a brief overview of the Rationale for Symptom Rating.
• Click on a scale number for rating criteria for each symptom on that scale.

    Symptoms occur on a continuum.  Generally, the more frequent a symptom occurs or the more severe it is in its effects, the more serious the symptom is rated.  The rating categories which follow provide some general guidelines for rating symptoms on the CCSI.  Each symptom also has specific guidelines which are included in the sections which follow.

    Choose the number which best describes your experience of the symptom.

    Here are some general criteria for rating the severity of symptoms on the CCSI:
 

0 = NO OR NONE

    If you have not had any problem with this symptom during the past 12 months, enter "0".
 

1 = MILD

    If you are aware of having a problem with this symptom during the past 12 months but have not sought professional treatment it is probably a "mild" rating.  You may be using an "over the counter medication" or some form of self-treatment.  Also, a mild level probably does not seriously affect the quality of your life or cause you significant discomfort.  An examples of this level would be an occasional mild headache of short duration.
 

2 = MODERATE

    You may seek treatment for the moderate level of a symptom.  A moderate symptom may affect the quality of your life although you can probably do most activities that you would normally do.  A moderate symptom will usually cause notable discomfort and distress.  You may find that you avoid certain activities or are required to make adjustments in your daily activities because of a moderate symptom.  You may have discussed the symptom with your doctor and received a prescription or some form of professional treatment.  An example of this level would be fairly frequent headaches or increasing pain levels that cause you to miss work or other daily activities from time to time.
 

3 = SEVERE

    You are very likely to seek treatment when a symptom is "severe."  Severe symptoms usually cause great discomfort and adversely affect the quality of your life.  You may be partially or fully disabled from a severe symptom.  An example of this level would be chronic and debilitating headaches (such as migraine) that make it difficult to have a normal life.

• Cold extremities
• Itchy or dry skin
• Skin blemishes (eczema, psoriasis, rash, acne, etc.)
• Hands or feet are numb or fall asleep
• Lumps or tumors under skin

"During the past 12 months, have you had problems with cold hands or feet?"

• 1  Mild = Your hands or feet are sometimes cold, or are only slightly cold.
• 2  Moderate = Your hands or feet are often cold, or are cold enough to be uncomfortable.
• 3  Severe = Your hands or feet are almost always cold, even during the summer when you are very uncomfortable in air conditioned buildings because the temperature of your extremities drop to the same level as the room you are in.

"During the past 12 months, have you had problems with itchy or dry skin?"

• 1  Mild = You sometimes have a little itchiness or dryness of skin but usually ignore it.
• 2  Moderate = You often have itchy or dry skin and usually try to treat it in some way because it is noticeable or uncomfortable.
• 3  Severe = Your skin is almost always itchy and/or dry which really is extremely annoying and/or uncomfortable for you.  You have probably used one or more skin products on a regular basis for symptomatic relief.

"During the past 12 months, have you had problems with skin blemishes such as eczema, psoriasis, rash, acne, etc.?"

• 1  Mild = You sometimes have minor skin blemishes that you usually ignore.
• 2  Moderate = You often have skin blemishes which you try to treat or cover up because they are unsightly.
• 3  Severe = You almost always have very notable skin blemishes which can affect choices you make about the clothes you wear, etc.  These skin blemishes are an extremely embarrassing problem which causes you much misery.

"During the past 12 months, have you had problems with your hands or feet feeling numb or falling asleep?"

• 1  Mild = You sometimes have this problem but it is very minor and you ignore it.
• 2  Moderate = You often have this problem and find it quite annoying to the point that you have tried to find out why this is happening and what can be done about it.
• Severe = This is an extremely annoying problem that causes you much concern.  This problem may be affecting your ability to work or play.

"During the past 12 months, have you had problems with lumps or tumors under your skin?"

• 1  Mild = You sometimes have small lumps or tumors just under the skin that go away and cause you little concern.  You have not even bothered to mention it to your physician nor have you sought treatment for this problem.
• 2  Moderate = You often have lumps or tumors just under the skin which you have discussed with your physician and been assessed or treated.
• 3  Severe = You almost always have lumps or tumors just under the skin which cause you great concern.  You have been treated for this chronic problem but it still recurs.

• Kidney or bladder problems
• Cold, clamminess over body
• Cold area on abdomen
• Tiredness or fatigue
• Constipation
• Stomach or intestinal gas

"During the past 12 months, have you had problems with kidney or bladder problems?"

• 1  Mild = You sometimes experience mild kidney problems such as excessive or decreased urination or mild irritation when urinating.  You have not sought medical treatment for this minor problem.
• 2  Moderate = You often experience kidney and bladder symptoms that are somewhat distressing.  You have sought assessment and/or treatment for this problem.  However, you are able to do any activity that you want and do not regard this as a major obstacle to having a high quality of life.
• 3  Severe = You almost always experience significant kidney and bladder problems that are very uncomfortable or painful (e.g., infection, inflammation, burning sensation during urination, etc.).  You probably have to adjust your daily activities such as work or play because of this problem.  You have sought assessment and/or treatment for this problem and regard it as a serious obstacle to high quality of life.

"During the past 12 months, have you noticed feeling cold and clammy?"
(Note: clammy means "damp, moist, sticky, sweaty, or wet.")

• 1  Mild = You sometimes feel cool and damp but you ignore it and have not sough medical assessment or treatment for this symptom.
• 2  Moderate = You often feel cool and clammy and find it somewhat disturbing.  You may have discussed this problem with your physician.
• 3  Severe =  You almost always experience a cold, clammy feeling that is very upsetting or distressing to you.  You have probably discussed this with a health practitioner or tried to remedy the condition in some way.

"During the past 12 months, have you noticed a cool or cold area anywhere on your abdomen?"

• 1  Mild = You sometimes notice a cool area on your abdomen.
• 2  Moderate = You often notice a cool area on your abdomen.
• 3  Severe =  You often notice a very cool or cold area on your abdomen.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you had problems with stomach or intestinal gas?"

• 1  Mild = You sometimes experience mild stomach or intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive burping or flatulence.
• 2  Moderate = You often experience stomach or intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience stomach or intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

• Stomach or intestinal gas
• Indigestion
• Nausea
• Headaches
• Bad taste in mouth
• Constipation
• Anemia
• General weakness and lack of energy or vitality

"During the past 12 months, have you had problems with stomach or intestinal gas?"

• 1  Mild = You sometimes experience mild stomach or intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive burping or flatulence.
• 2  Moderate = You often experience stomach or intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience stomach or intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

"During the past 12 months, have you had problems with indigestion or sour stomach?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion which is distressing.  Some foods seem to "sour" in your stomach. You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with nausea after eating?"

• 1  Mild = You sometimes experience nausea after eating but usually ignore it.
• 2  Moderate = You often experience nausea after eating which is quite distressing to you.  You probably avoid certain foods or take digestive aids to avoid this problem.
• 3  Severe = You almost always experience nausea after eating which is extremely distressing to you.  You probably have sought help from a health professional to relieve this problem.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you noticed a bad taste in your mouth?"

• 1  Mild = You sometimes notice a bad taste in your mouth.
• 2  Moderate = You often notice a bad taste in your mouth.
• 3  Severe = You almost always notice a bad taste in your mouth.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you had problems with anemia?"

• 1  Mild = You think that you may be anemic but have not been troubled enough with it to seek medical treatment.
• 2  Moderate = You know that you have problems with anemia and am taking a supplement or some form of medical treatment.  The treatment seems to be helping you to the point that you are able to live your life as you wish.
• 3  Severe = You have a serious problem with anemia which may not be responding very well to treatment.  Even with treatment you feel weak which decreases your quality of life because it limits the activities that you can do.

"During the past 12 months, have you had problems with general weakness, lack of energy or vitality?"

• 1  Mild = You sometimes feel weak and low on energy or vitality.  You just rest more often and ignore the condition because it doesn't seem to be a serious problem.
• 2  Moderate = You often feel generally weak and lacking in energy or vitality.  This is a problem for you and you have sought professional help or are taking some form of treatment for the condition.
• 3  Severe = You almost always feel generally weak and lacking in energy or vitality.  You have sought help from a health professional.  You may have been diagnosed with chronic fatigue syndrome (CFS).  This problem is so severe that it prevents you from living a normal, active life.

• Heartburn
• Belching
• Indigestion
• Regurgitation of food
• Constipation

"During the past 12 months, have you had problems with heartburn?"

• 1  Mild = You sometimes experience mild heartburn or acid reflux which you ignore.
• 2  Moderate = You experience heartburn which is distressing enough to cause you to avoid certain foods or take a digestive aid to decrease acidity.
• 3  Severe = You almost always experience heartburn or the heartburn is so severe as to be extremely distressing.  You have probably discussed this problem with a health professional and may be receiving treatment for the condition.

"During the past 12 months, have you had problems with belching?"

• 1  Mild = You sometimes belch but don't consider it to be a significant problem.
• 2  Moderate = You often belch and find it distressing.  You may have tried digestive aids or avoid certain foods.
• 3  Severe = You almost always experience this problem, or when you do belch it is so distressing or even painful that you have sought help from a health professional.

"During the past 12 months, have you had problems with indigestion?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with regurgitation of food?"

• 1  Mild = You sometimes experience mild regurgitation of food into your mouth and although it is annoying, you don't consider it to be a significant problem.
• 2  Moderate = You often experience regurgitation of food and find it distressing to the point that you use digestive aids or avoid certain foods.
• 3  Severe = You almost always experience regurgitation of food and find it extremely distressing.  You have probably discussed this problem with a health professional and may be receiving treatment for the condition.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

• Catches cold easily
• Prone to severe colds
• Prone to congestion (head, throat or lungs)
• Irregular or fast pulse
• Tiredness or fatigue
• Abnormal appetite (increased, decreased, erratic)
• Skin rash
• Headaches
• Indigestion
• Hemorrhoids
• Stomach or intestinal gas
• Chronic muscle pain or diagnosis of fibromyalgia

"During the past 12 months, have you caught cold easily?"

• 1  Mild = You caught cold 2 times during the past 12 months.
• 2  Moderate = You caught cold 3 times during the past 12 months.
• 3  Severe = You caught cold 4 or more times during the past 12 months.

"During the past 12 months, have you been prone to develop severe colds?"

• 1  Mild = You developed a severe cold 2 times during the past 12 months.
• 2  Moderate = You developed a severe cold 3 times during the past 12 months.
• 3  Severe = You developed a severe cold 4 or more times during the past 12 months.

"During the past 12 months, have you been prone to congestion of the head, throat or lungs?"

• 1  Mild = You sometimes notice a little congestion but ignore it.
• 2  Moderate = You are often aware of congestion and find it annoying enough to use nonprescription medicine for symptomatic relief.
• 3  Severe = You almost always experience congestion which may be distressing enough that you have sought professional treatment.  You may have been diagnosed with allergies or sensitivities to certain substances.

"During the past 12 months, have you had irregular or fast pulse?"

• 1  Mild = You sometime notice that your pulse is a little fast or irregular but you ignore it because it doesn't seem to be a serious problem.
• 2  Moderate = You often experience irregular or fast pulse which concerns you to the extent that you have discussed this problem with a health professional and may be receiving treatment for the condition.
• 3  Severe = You almost always experience irregular or fast pulse which is very distressing to you.  You have definitely sought help from a health professional because this seems to indicate that something is wrong with your cardiovascular system.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you had problems with abnormal appetite which may be increased, decreased, or erratic?"

• 1  Mild = You sometimes notice that your appetite is not quite normal but don't consider it to be a serious problem.  You just ignore it.
• 2  Moderate = You often notice that your appetite is not normal and may have discussed this problem with a health professional.  The problem is somewhat annoying and you are concerned that something may be wrong with your digestive system.
• 3  Severe = You almost always experience abnormal appetite which may fluctuate between increased and decreased desire for food.  You find this very annoying or distressing and you have probably sought professional help in dealing with this problem.

"During the past 12 months, have you had problems with skin rash?"

• 1  Mild = You sometimes notice a little skin rash which is not serious.  You ignore it.
• 2  Moderate = You often notice skin rash which is significant and bothersome.  You probably use some form of treatment for symptomatic relief.  You may have discussed this problem with a health professional.
• 3  Severe = You almost always experience skin rash which may be extensive.  You find this very distressing and have definitely sought help from a health professional.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you had problems with indigestion?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with hemorrhoids?"

• 1  Mild = You sometimes experience mild discomfort from hemorrhoids.  You may use a simple nonprescription treatment for relief or you just ignore it.
• 2  Moderate = You often experience discomfort from hemorrhoids and regularly use some form of treatment.  You may have discussed this problem with a health professional.
• 3  Severe = Hemorrhoids are a serious problem for you for which you have definitely sought professional assistance.  You often find yourself miserable from this condition.

"During the past 12 months, have you had problems with stomach or intestinal gas?"

• 1  Mild = You sometimes experience mild stomach or intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive burping or flatulence.
• 2  Moderate = You often experience stomach or intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience stomach or intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

"During the past 12 months, have you had problems with chronic muscle pain?"

• 1  Mild = You sometimes experience mild muscle pain which is excessive and cannot be directly attributed to activities involving exercise (such as work or recreation).
• 2  Moderate = You often experience chronic muscle pain that is very distressing and somewhat debilitating.  You are probably taking some form of medicine or treatment for this problem.
• 3  Severe = You almost always experience chronic muscle pain which is extremely distressing.  You are probably limited in your work and recreation activities or may be partially or fully disabled.  You may have been diagnosed with fibromyalgia.  You have sought help from a health professional for this serious problem.

• Indigestion
• Constipation
• Dull headaches
• Pain or heaviness along right side of abdomen
• Bad breath or bad taste in mouth not due to food or drink
• General dullness or drowsiness
• Gallstones or gallbladder problems
• Burning or irritation to eyes
• Dizziness

"During the past 12 months, have you had problems with indigestion?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you suffered from "dull" headaches?"

• 1  Mild = You sometimes have "dull" headaches which you either ignore or self-medicate with nonprescription remedies.
• 2  Moderate = You often have "dull" headaches which are distressing and somewhat disabling.  You have probably discussed with problem with a health professional and may be receiving treatment.
• 3  Severe = You almost always have "dull" headaches which are extremely distressing and disabling.  You definitely have sought the help of a health professional for this problem.

"During the past 12 months, have you been bothered by pain or heaviness along the right side of the abdomen?"

• 1  Mild = You sometimes notice a little discomfort in this area but ignore it because it doesn't seem serious enough to warrant attention.
• 2  Moderate = You are often aware of this symptom or when it occurs it is distressing enough for you to seek some form of symptomatic relief.  You may have discussed this problem with a health professional.
• 3  Severe = You are almost always aware of pain or heaviness along the right side of the abdomen which is quite distressing.  You have probably sought symptomatic relief and have likely discussed this symptom with a health professional.

"During the past 12 months, have you been bothered with bad breath or a bad taste in your mouth which is not directly due to food or drink."

• 1  Mild = You sometimes notice this symptom but ignore it or use mouth wash or such to cover it up.  The bad breath or bad taste is not directly due to specific food just eaten (such as onions or garlic).
• 2  Moderate = You often notice this symptom and find it annoying because it doesn't seem to be linked to anything that you have eaten (such as onions or garlic) which could account for it.  You may have been criticized by friends or family and may be somewhat sensitive to this issue.  Of course you are using mouthwash, mints or whatever which does not seem to addressing the cause of the problem.
• 3  Severe = You almost always notice this symptom and it is very distressing to the extent that you may avoid certain social situations or take extreme caution to avoid embarrassment.  Or the bad taste in your mouth is so annoying that you are concerned that you may have a dental or hygiene problem.

"During the past 12 months, have you been plagued with general dullness or drowsiness?"

• 1  Mild = You sometimes experience this symptom but ignore it.
• 2  Moderate = You often experience this symptom and take certain measures (such as naps or exercise) to increase your energy or help you to be more alert.
• 3  Severe = You almost always feel dull or drowsy which is very distressing to you.  You may feel that it is adversely affecting your normal activities (such as work or recreation) and decreases the quality of your life.  You may have sought the advice of a health professional or be receiving treatment for this annoying problem.

"During the past 12 months, have you had problems with gallstones or your gallbladder?"

• 1  Mild = You sometimes notice discomfort on the right side of your abdomen a few hours after eating and when the stomach is empty.  You usually ignore it or take a simple remedy for symptomatic relief.
• 2  Moderate = You often experience pain or discomfort in the area of the gallbladder or other signs indicative of a problem which this organ.  Pains radiating to the area of the right shoulder or arm are common with gallbladder problems.
• 3  Severe = You have had serious gallbladder problems such as recurrent attacks.  You have sought help from a health professional and are receiving some form of treatment.  You may have had your gallbladder removed.

"During the past 12 months, have you experienced burning or irritation to your eyes?"

• 1  Mild = You sometimes notice a slight irritation to your eyes.
• 2  Moderate = You often notice a burning sensation or irritation to the eyes.  You probably have sought some form of symptomatic relief for this annoying condition.
• 3  Severe = You experience painful burning sensation or strong irritation to your eyes which may be frequent.  You have probably discussed this problem with a health professional and are receiving some form of treatment (even if symptomatic) to relief the condition.

"During the past 12 months, have you had problems with dizziness?"

• 1  Mild = You sometimes experience mild dizziness which does not seem serious enough to warrant medical attention.
• 2  Moderate = You often experience dizziness which concerns you enough to seek professional help.  You may be taking some form of treatment for the problem.
• 3  Severe = Dizziness is a serious problem for you.  You have sought professional treatment and probably have adjusted your lifestyle to some extent to avoid dangerous or awkward situations.

• Impaired or distorted sense of taste
• Impaired or distorted sense of smell
• Impaired or distorted sense of vision
• Impaired or distorted hearing or tinnitus
• Feeling of fullness in throat or face
• Supersensitive reactions to sounds, actions, smells, etc.

"During the past 12 months, have you had problems with your sense of taste?"

• 1  Mild = You sometimes notice that you have lost some of this sense or it has become distorted.  Food don't taste quite right.  You are not too bothered by this and ignore it.
• 2  Moderate = You often notice that your sense of taste has been affected and you find this very annoying.
• 3  Severe = You almost always experience distorted or lost sense of taste.  You find this very distressing and may have discussed this problem with a health professional.

"During the past 12 months, have you had problems with your sense of smell?"

• 1  Mild = You sometimes notice that you have lost some of this sense or it has become a little distorted.  You are not too bothered by this loss and ignore it.
• 2  Moderate = You often notice that your sense of smell has been affected and you find this very annoying (although at times it can be a blessing!).
• 3  Severe = You almost always experience distorted or lost sense of smell.  You find this very distressing and may have discussed this problem with a health professional.

"During the past 12 months, have you had problems with your vision?"

• 1  Mild = You have lost some of this sense or it has become distorted.  If you where glasses or contacts, this is at least a mild symptom.
• 2  Moderate = You often notice that your vision is distorted (whether you are wearing glasses/contacts or not).  This distortion may come and go erratically.  Or, your vision has become progressively worse requiring stronger prescriptions or other interventions.
• 3  Severe = You almost always experience significant visual problems requiring professional treatment.  You vision remains somewhat impaired or distorted despite appropriate treatment.  You may have to adjust your daily activities accordingly.  The quality of your life is diminished.

"During the past 12 months, have you had problems with hearing."

• 1  Mild = You sometimes experience hearing problems or mild tinnitus (ringing in the ears or similar phenomenon).  You do not consider this to be a serious problem and ignore it.
• 2  Moderate = You often or regularly experience significant hearing loss or distortion.  You may have sought professional treatment.  You find this at least annoying and are probably distressed over this condition.
• 3  Severe = You almost always experience significant hearing loss or distortion.  You may have been diagnosed with tinnitus or other hearing disease.  You have sought the help of a health professional and received some form of treatment.  This is a serious symptom which diminishes your quality of life.

"During the past 12 months, have you experienced a feeling of fullness in your throat or face?"

• 1  Mild = You sometimes notice a feeling of fullness which may be strange or even uncomfortable.  However, you ignore this symptoms as not being serious enough to warrant treatment.
• 2  Moderate = You often experience this symptom which can be somewhat annoying or even distressing.  Because it is a rather vague sensation, you may have trouble describing it to a health professional.  You may have tried nonprescription remedies for symptomatic relief.
• 3  Severe = You almost always experience this sense of fullness which is very distressing.  You may at time feel a slight choking sensation because of this feeling of fullness.  You may have discussed this problem with a health professional.

"During the past 12 months, have you noticed that you have supersensitive reactions to sound, actions, smells, or other environmental stimuli?"

• 1  Mild = You sometimes notice that you are sensitive or reactive to things going on around you.  However, your reaction is to simply ignore it or withdraw from the situation if it becomes too annoying.
• 2  Moderate = You are often aware that you are very sensitive to stimuli from the environment.  You find this distressing and seek relief with nonprescription remedies or perhaps you have discussed this with a physician who has prescribed a mild sedative or such.
• 3  Severe = You are almost always aware of being supersensitive to sensory stimuli.  Sounds, smells, and actions which are innocuous to others are often oppressive to you.  You are easily overloaded by your senses.  You have probably adapted your lifestyle to avoid overstimulation.  You may have sought professional help which may include counseling or psychotherapy to decrease your anxiety or assist with developing strategies to diminish your supersensitivity.  You may even find yourself becoming supersensitive to the content and style of what others say in addition to the purely physical aspect of sensation.

• Decreased urination
• Urine has strong odor
• Burning sensation during urination
• Puffy under eyes or burning of eyes or blurred/dimmed vision
• Swelling or heaviness in lower extremities
• Aching muscles and/or joints (rheumatism)

"During the past 12 months, have you had problems with decreased urination?"

• 1  Mild = You sometimes notice a decrease in urination (either less frequent or less volume), but are not particularly concerned about it.
• 2  Moderate = You often notice decreased urination which does somewhat concern you.  You may have discussed this with a health professional.  You may be taking simple precautions such as drinking more water.
• 3  Severe = You almost always experience decreased urination and are very concerned about it.  You have probably discussed this with a health professional and may be receiving treatment for the condition.

"During the past 12 months, have you noticed that your urine has a strong odor?"

• 1  Mild = You sometimes notice this symptom but are not concerned and ignore it.
• 2  Moderate = You often notice this symptom and may be concerned about it.
• 3  Severe = You almost always notice this symptom.  The odor is very strong and unpleasant.  You may have discussed this symptom with a health professional.

"During the past 12 months, have you experienced a burning sensation during urination?"

• 1  Mild = You sometimes notice a burning sensation during urination which is not very painful so you ignore it.
• 2  Moderate = You often experience a burning sensation during urination which is distressing to you.  You have probably discussed this problem with a health professional.
• 3  Severe = You almost always experience this symptom.  Or when you do experience it, it is so painful that you have sought professional help with this problem.

"During the past 12 months, have you experienced problems with your eyes such as puffiness under you eyes, burning sensation in your eyes, or blurred or dimmed vision?"

• 1  Mild = You sometimes experience one or more of these difficulties but they are not particularly annoying so you ignore them.
• 2  Moderate = You often experience one or more of these problems which is distressing to you.  You may have sought professional help or used nonprescription remedies for symptomatic relief.
• 3  Severe = You almost always experience one or more of these conditions. Or, when you do have these problems, they are very severe.  You have probably sought professional treatment for these symptoms.

"During the past 12 months, have you had problems with swelling or a feeling of heaviness in your lower extremities?"

• 1  Mild = You sometimes notice a little swelling or feeling of heaviness in your legs, ankles or feet which you ignore.
• 2  Moderate = You often notice these problems which are distressing enough for you to use some form of treatment for symptomatic relief.  You may have discussed this problem with a health professional.
• 3  Severe = You almost always experience these symptoms, or when you do experience them they are quite painful and/or distressing.  You have probably sought help from a health professional.  You may experience considerable misery from these symptoms.

"During the past 12 months, have you had problems with aching muscles and/or joints?"

• 1  Mild = You sometimes experience a little discomfort due to aching muscles and/or joints which cannot be attributed solely to activities such as work or recreation.  You probably ignore the problem, because it is not serious enough to warrant medical treatment.  You may use a simple nonprescription remedy for symptomatic relief.
• 2  Moderate = You often experience significant muscle and/or joint pain (sometimes called rheumatism).  You have probably sought professional treatment for these annoying symptoms but are able to maintain a relatively high quality of life with little or no alteration in normal life activities.
• 3  Severe = You almost always experience significant muscle and/or joint pain for which you have sought professional treatment.  Your quality of life is probably diminished and you may even be partially or fully disabled.

• High blood pressure or palpitations
• Headache
• Lower back pain or sciatic pain
• Tiredness or fatigue
• Constipation

"During the past 12 months, have you had problems with high blood pressure or palpitations?"

• 1  Mild = You sometimes have high blood pressure or palpitations.
• 2  Moderate = You often have high blood pressure or palpitations.  You have probably discussed this with a health professional.
• 3  Severe = You almost always suffer from high blood pressure or palpitations.  You are probably under treatment for these cardiovascular symptoms.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you suffered from lower back pain or sciatic pain?"

• 1  Mild = You sometimes have mild lower back pain or sciatic pain (extending down the leg).  You may use nonprescription remedies for symptomatic relief.
• 2  Moderate = You often have lower back pain or sciatic pain which is quite distressing.  You probably receive some form of treatment and have probably discussed this problem with a health professional.
• 3  Severe = You almost always have lower back pain or sciatic pain, or when you do have these symptoms they are extremely distressing.  You probably have seen a health professional for assessment and treatment.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

• Dental problems such as weak enamel or cavities
• Dry, faded, or thinning hair
• Finger nails split or break off
• Poor resistance to disease
• Low blood pressure or poor circulation to extremities
• Weak bones, bone loss, or bone deformity
• Underactive thyroid
• Tiredness or fatigue
• Respiratory problems

"During the past few years, have you had dental problems such as weak enamel or cavities?"

• 1  Mild = You have had some minor dental problems involving weak enamel or cavities.
• 2  Moderate = You have several cavities or a general worsening in your dental health.
• 3  Severe = You have had considerable dental work done due to weak enamel or cavities.

"During the past 12 months, have you had dry, faded, or thinning hair?"

• 1  Mild = You have noticed a little dryness, fading, or thinning of your hair.
• 2  Moderate = You have noticed quite a bit of drying, fading, or thinning of your hair which has caused you some concern.
• 3  Severe = You have experienced considerable drying, fading, or thinning of your hair which has been very worrisome to you.

"During the past 12 months, have you had problems with finger nails that split or break off?"

• 1  Mild = You sometimes notice a tendency for your nails to split or break off.
• 2  Moderate = You often notice definite splitting or breaking off of your nails.
• 3  Severe = Your nails split or break off almost all the time.

"During the past 12 months, have you experienced poor resistance to disease?"

• 1  Mild = You sometimes come down with illness easily but you heal fairly soon.
• 2  Moderate = You often come down with illness easily and do not heal quickly.
• 3  Severe = You seem to almost always come down with disease to which you are exposed and are very slow to heal.

"During the past 12 months, have you had problems with low blood pressure or poor circulation to your extremities?"

• 1  Mild = You sometimes have low blood pressure or poor circulation to your hands or feet.
• 2  Moderate = You often have low blood pressure or poor circulation to your hands or feet.
• 3  Severe = You almost always have low blood pressure or poor circulation to your hands or feet.

"During the past 12 months, have you had problems with weak bones, bone loss, or bone deformity?"

• 1  Mild = You have noticed a tendency toward these symptoms but have not taken action to remedy the problem.
• 2  Moderate = You have definitely experienced these symptoms but are able to live a fairly normal life with little restriction to your normal activities.  You may be receiving treatment for the condition.
• 3  Severe = You have experienced serious problems due to weak bones, bone loss, or bone deformity.  You have sought professional help and are being treated.  You quality of life has been decreased due to limitations on the kind of activities which you can safely do.

"During the past 12 months, are you aware of having an underactive thyroid?"

• 1  Mild = You are aware of having an underactive thyroid but have not sought professional help in treating the condition because you don't consider it very serious.
• 2  Moderate = You are aware of having an underactive thyroid and have sought treatment from a health professional or are treating yourself with nonprescription remedies.  You are suffering from some of the well known symptom of this problem, but your quality of life has not been affected.
• 3  Severe = You have an underactive thyroid that has been medically diagnosed.  You are receiving treatment for this condition because otherwise it does seriously affect your quality of life.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you had respiratory problems?"

• 1  Mild = You sometimes have minor respiratory problems such as coughs and infections which heal easily and do not limit your activities to any great extent.  You may use nonprescription remedies for symptomatic relief.
• 2  Moderate = You often have respiratory problems.  You have probably sought professional help and receive treatment as needed for symptomatic relief.  Your quality of life is not seriously affected - you can do pretty much anything you wish when you are not having an acute episode.
• 3  Severe = You have chronic respiratory problems ranging from minor infections to serious illness.  You have definitely sought professional help because the problem has had a significant negative effect on your quality of life.

• Excessive bleeding (lack of clotting) or wounds heal slowly
• Low resistance to disease or lack of vitality
• Cysts or tumors
• Blotches, spots or bruises on surface of body

"During the past 12 months, have you had problems with excessive bleeding or wounds that heal slowly?"

• 1  Mild = You sometimes notice that you tend to bleed a lot or that wounds heal slowly.  Since it doesn't seem to affect you otherwise, you are not very concerned about this tendency.
• 2  Moderate = You often notice that you are prone to excessive bleeding or that your wounds take a very long time to heal.  This is a concern to you.  You may have discussed it with a health professional.
• 3  Severe = You almost always bleed excessively or heal very slowly.  You have probably discussed this with a health professional and take it into consideration when requiring treatment such as surgery.  You take special precautions to avoid injury or illness because of this problem.

"During the past 12 months, have you had problems with low resistance to disease or lack of vitality?"

• 1  Mild = You sometimes come down with illness easily but you heal fairly soon.
• 2  Moderate = You often come down with illness easily and do not heal quickly.  You have a sense that your vitality is low.
• 3  Severe = You seem to almost always come down with disease to which you are exposed.  You have a notable lack of vitality and feel vulnerable to infection or any contagious disease.

"During the past 12 months, have you had cysts or tumors?"

• 1  Mild = You sometimes have minor cysts or tumors which you ignore.
• 2  Moderate = You often have cysts or tumors which causes you considerable concern.  You have probably discussed this with a health professional and sought treatment for the condition.
• 3  Severe = You almost always have cysts or tumors.  This chronic problem is likely to be a source of very great distress as you worry about cancer.  You may have developed cancer.  You have sought professional assistance with this problem.

"During the past 12 months, have you had problems with blotches, spots or bruises on the surface of your body?"

• 1  Mild = You sometimes notice these blemishes on your body but this seems to be a minor problem that you ignore.
• 2  Moderate = You often experience these blemishes and are probably concerned enough to seek professional help or use a nonprescription treatment.
• 3  Severe = You almost always have these blemishes which causes you considerable distress.  You have probably sought professional help and treatment.  The severity of this problem affects your quality of life because of the embarrassment associated with skin blemishes.  You may choose certain clothing or avoid certain situations because of this problem.

• Swelling or heaviness in lower extremities
• Lower back pain (lumbago)
• Burning or irritation of eyes or dimness of vision
• Dizziness
• Nausea
• Headache

"During the past 12 months, have you had problems with swelling or a feeling of heaviness in your lower extremities?"

• 1  Mild = You sometimes notice a little swelling or feeling of heaviness in your legs, ankles or feet which you ignore.
• 2  Moderate = You often notice these problems which are distressing enough for you to use some form of treatment for symptomatic relief.  You may have discussed this problem with a health professional.
• 3  Severe = You almost always experience these symptoms, or when you do experience them they are quite painful and/or distressing.  You have probably sought help from a health professional.  You may experience considerable misery from these symptoms.

"During the past 12 months, have you had problems with lower back pain (lumbago)?"

• 1  Mild = You sometimes have a little lower back pain.  You may use a nonprescription remedy for symptomatic relief.  You don't consider it to be serious enough to seek professional help.
• 2  Moderate = You often experience lower back pain that causes you significant distress.  You have probably sought professional help and are receiving some form of treatment for his condition.
• 3  Severe = You almost always have lower back pain or when you do have this pain it is so great to be a serious health issue for you.  You have sought professional help for this extremely distressing problem.  This pain lowers your quality of life and limits the kinds of activities that you can do.  You may suffer partial or complete disability because of the pain.

"During the past 12 months, have you experienced burning or irritation to your eyes or dimness of vision?"

• 1  Mild = You sometimes notice a slight irritation to your eyes or a little dimness of vision.
• 2  Moderate = You often notice a burning sensation or irritation to the eyes or notable dimness of vision.  You probably have sought some form of symptomatic relief for this annoying condition.
• 3  Severe = You experience painful burning sensation or strong irritation to your eyes which may be frequent.  Or, you have developed considerable dimness of vision in addition to any other vision problems you may have had (such as wearing glasses).  You have probably discussed this problem with a health professional and are receiving some form of treatment (even if symptomatic) to relief the condition.

"During the past 12 months, have you had problems with dizziness?"

• 1  Mild = You sometimes experience mild dizziness which does not seem serious enough to warrant medical attention.
• 2  Moderate = You often experience dizziness which concerns you enough to seek professional help.  You may be taking some form of treatment for the problem.
• 3  Severe = Dizziness is a serious problem for you.  You have sought professional treatment and probably have adjusted your lifestyle to some extent to avoid dangerous or awkward situations.

"During the past 12 months, have you had problems with nausea?"

• 1  Mild = You sometimes experience nausea but usually ignore it.
• 2  Moderate = You often experience nausea which is quite distressing to you.  You probably avoid certain foods or take digestive aids to avoid this problem.  Or, you use nonprescription remedies which are intended to reduce nausea.

3  Severe = You almost always experience nausea which is extremely distressing to you.  You probably have sought help from a health professional to relieve this problem.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

• Abnormal appetite (increased, decreased, or erratic)
• Indigestion or high acidity in stomach, throat, or mouth
• Stomach or intestinal gas
• Abnormal heart action (low or high) or discomfort around heart
• Stomach empties too slowly or too quickly after eating
• Headaches
• Nausea
• Constipation

"During the past 12 months, have you had problems with abnormal appetite which may be increased, decreased, or erratic?"

• 1  Mild = You sometimes notice that your appetite is not quite normal but don't consider it to be a serious problem.  You just ignore it.
• 2  Moderate = You often notice that your appetite is not normal and may have discussed this problem with a health professional.  The problem is somewhat annoying and you are concerned that something may be wrong with your digestive system.
• 3  Severe = You almost always experience abnormal appetite which may fluctuate between increased and decreased desire for food.  You find this very annoying or distressing and you have probably sought professional help in dealing with this problem.

"During the past 12 months, have you had problems with indigestion or high acidity in your stomach, throat or mouth?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating which may include acid indigestion or acid reflux into the throat or mouth.  You don't regard this as a serious problem and ignore it.
• 2  Moderate = You often experience significant indigestion, heartburn, or acid reflux which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion or high acidity which is very distressing to you.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with stomach or intestinal gas?"

• 1  Mild = You sometimes experience mild stomach or intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive burping or flatulence.
• 2  Moderate = You often experience stomach or intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience stomach or intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

"During the past 12 months, have you been bothered by abnormal heart action (low or high) or discomfort around your heart?"

• 1  Mild = You sometimes notice that your heart is beating too fast or slow or you notice a little discomfort in your chest around the heart.  This seems to be a minor problem which you ignore.
• 2  Moderate = You often notice abnormal heart action or chest discomfort which is very annoying and concerns you very much.  You have probably discussed this with a health professional and may be receiving treatment.
• 3  Severe = You almost always experience one or both of these symptoms and are very troubled by it.  You have almost certainly sought professional help and are receiving some form of treatment.  You may alter your lifestyle or activities to avoid stressing your system.

"During the past 12 months, have you noticed that your stomach empties too slowly or too quickly after eating?"

• 1  Mild = You sometimes notice that food stays to long in your stomach or that your stomach empties too fast.  However, this does not seem to be a serious problem so you ignore it.
• 2  Moderate = You often sense that your stomach is not emptying properly which causes you distress such as indigestion or nausea.  Or, you may notice that if the stomach empties too fast that you have problems further down in the GI tract (intestines) which is very worrisome.  You may have discussed this with a health professional and may be using some remedy to improve digestion in the stomach.
• 3  Severe = You almost always sense that your stomach does not empty properly.  This is a source of very great distress to you.  You have to be very careful of what you eat.  You have probably sought professional help for this condition.  You may feel depleted from poor digestion or assimilation of nutrients.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you had problems with nausea after eating?"

• 1  Mild = You sometimes experience nausea after eating but usually ignore it.
• 2  Moderate = You often experience nausea after eating which is quite distressing to you.  You probably avoid certain foods or take digestive aids to avoid this problem.
• 3  Severe = You almost always experience nausea after eating which is extremely distressing to you.  You probably have sought help from a health professional to relieve this problem.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

• Skin blemishes
• Swollen or painful joints (arthritis or rheumatism)
• Indigestion or stomach or intestinal gas
• Tender spots or painful areas over the body
• Nasal congestion (catarrh) or sinus problems
• Headache
• Depression
• Constipation

"During the past 12 months, have you had problems with skin blemishes such as eczema, psoriasis, rash, acne, etc.?"

• 1  Mild = You sometimes have minor skin blemishes that you usually ignore.
• 2  Moderate = You often have skin blemishes which you try to treat or cover up because they are unsightly.
• 3  Severe = You almost always have very notable skin blemishes which can affect choices you make about the clothes you wear, etc.  These skin blemishes are an extremely embarrassing problem which causes you much misery.

"During the past 12 months, have you had problems with swollen or painful joints?"

• 1  Mild = You sometimes experience mild joint pain which you either ignore or treat with simple nonprescription remedies.
• 2  Moderate = You often experience joint pain or swelling which is quite distressing to you.  You may have sought professional help for this and are using some form of treatment for symptomatic relief.
• 3  Severe = You almost always experience swollen or painful joints which is a serious problem for you.  You have sought professional help and are probably treating the condition.  This problem has decreased your quality of life by limiting activities (work and recreation) that you can do.

"During the past 12 months, have you had problems with indigestion or stomach or intestinal gas?"

• 1  Mild = You sometimes experience mild indigestion or stomach or intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive burping or flatulence.
• 2  Moderate = You often experience indigestion or stomach or intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to improve digestion and reduce gas.
• 3  Severe = You almost always experience indigestion or stomach or intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

"During the past 12 months, have you had problems with tender spots or painful areas over your body?"

• 1  Mild = You sometimes experience tenderness or mild muscle pain which cannot be directly attributed to activities involving exercise (such as work or recreation).
• 2  Moderate = You often experience tenderness or chronic muscle pain that is very distressing and somewhat debilitating.  You are probably taking some form of medicine or treatment for this problem.
• 3  Severe = You almost always experience tenderness or muscle pain which is extremely distressing.  You are probably limited in your work and recreation activities or may be partially or fully disabled.  You may have been diagnosed with fibromyalgia.  You have sought help from a health professional for this serious problem.

"During the past 12 months, have you had problems with nasal congestion (catarrh) or sinus problems?"

• 1  Mild = You sometimes have a little problem with these symptoms which you either ignore or treat with simple, nonprescription remedies.
• 2  Moderate = You often have problems with these symptoms which is very annoying.  You may have discussed this with a health professional.  You have probably used some form of treatment for symptomatic relief.
• 3  Severe = You almost always experience nasal congestion or sinus problems which is very distressing to you.  You have probably discussed this problem with a health professional and received some form of treatment.

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you had problems with depression?"

• 1  Mild = You sometimes feel a little depressed, but you carry on with your life and manage to do pretty well.  You have not talked with a health professional about it.
• 2  Moderate = You often feel depressed which is a significant problem for you.  You may have sought professional help for your depression.  You may be taking some form of treatment for it.  However, you are able to live a relatively normal life with little decrease to your quality of life because of depression.
• 3  Severe = You almost always feel depressed, or feel extremely depressed at times which significantly reduces your quality of life.  When you are depressed, you have great difficulty functioning.  You may be withdrawn or even suicidal.  You probably have sought and received professional help for this problem.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

• Dry or thinning hair or ends of hair split
• Nails brittle or thin, nails split or break, or peal around cuticle
• Chronic dental problems
• Dry or rough skin
• Depression
• Tiredness or fatigue
• Lack of interest in sex
• Fullness, contraction, or choking sensation in neck or throat
• Cold extremities
• Poor concentration
• Abnormal appetite (increased, decreased, or erratic)

"During the past 12 months, have you had dry or thinning hair, or hair with split ends?"

• 1  Mild = You sometimes notice a tendency toward one or more of these symptoms which you ignore.
• 2  Moderate = You often notice one or more of these symptoms which causes you some concern.  You may have discussed this problem with a health professional.  You may be taking nutritional supplements or other treatments to remedy this problem.
• 3  Severe = You almost always experience one or more of these symptoms which cause you very great distress.  You have probably discussed this with a health professional and are probably taking some form of treatment to address the condition.

"During the past 12 months, have you had finger or toe nails that are brittle or thin, split or broken, or pealing around the cuticle?"

• 1  Mild = You sometimes notice a tendency toward one or more of these symptoms which you ignore.
• 2  Moderate = You often notice one or more of these symptoms which causes you some concern.  You may have discussed this problem with a health professional.  You may be taking nutritional supplements or other treatments to remedy this problem.

3  Severe = You almost always experience one or more of these symptoms which cause you very great distress.  You have probably discussed this with a health professional and are probably taking some form of treatment to address the condition.

"During the past few years, have you had chronic dental problems?"

• 1  Mild = You have had some minor dental problems.
• 2  Moderate = You have several cavities or a general worsening in your dental health.

3  Severe = You have had considerable dental work done.

"During the past 12 months, have you had problems with dry or rough skin?"

• 1  Mild = You sometimes have dry or rough skin which you ignore because it is not a serious problem.
• 2  Moderate = You often have dry or rough skin which is very annoying.  You probably use some simple nonprescription remedy for symptomatic relief.
• 3  Severe = You almost always have dry or rough skin which can be very distressing.  You are using some form of treatment and may have discussed this problem with a health professional.

"During the past 12 months, have you had problems with depression?"

• 1  Mild = You sometimes feel a little depressed, but you carry on with your life and manage to do pretty well.  You have not talked with a health professional about it.
• 2  Moderate = You often feel depressed which is a significant problem for you.  You may have sought professional help for your depression.  You may be taking some form of treatment for it.  However, you are able to live a relatively normal life with little decrease to your quality of life because of depression.
• 3  Severe = You almost always feel depressed, or feel extremely depressed at times which significantly reduces your quality of life.  When you are depressed, you have great difficulty functioning.  You may be withdrawn or even suicidal.  You probably have sought and received professional help for this problem.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you noticed a lack of interest in sex?"

• 1  Mild = You sometimes feel that you have a low sex drive or have been told this by a partner.  But you don't consider it to be a serious problem and are not seeking help for it.
• 2  Moderate = You often experience a lack of interest in sex which causes you concern because it is abnormal for you or has caused friction between you and a partner.
• 3  Severe = You almost always experience lack of interest in sex which you recognize as a serious problem which decreases the quality of your life.  You may have discussed this problem with a health professional.  You may be receiving treatment to increase your interest in sex.

"During the past 12 months, have you experienced a feeling of fullness, contraction or choking sensation in your neck or throat?"

• 1  Mild = You sometimes experience one or more of these symptoms, but the sensation is mild and you ignore it.
• 2  Moderate = You often experience one or more of these symptoms which is very annoying.  Because it can be a rather vague sensation, you may have trouble describing it to a health professional.   You may be receiving treatment for this condition.
• 3  Severe = You almost always experience one or more of these symptoms which is extremely.  You have probably discussed this problem with a health professional because it is such an uncomfortable experience.

"During the past 12 months, have you had problems with cold hands or feet?"

• 1  Mild = Your hands or feet are sometimes cold, or are only slightly cold.
• 2  Moderate = Your hands or feet are often cold, or are cold enough to be uncomfortable.
• 3  Severe = Your hands or feet are almost always cold, even during the summer when you are very uncomfortable in air conditioned buildings because the temperature of your extremities drop to the same level as the room you are in.

"During the past 12 months, have you had problems with poor concentration?"

• 1  Mild = You sometimes have a little problem with concentration, but are able to function well enough that you don't consider it a serious problem.  You just ignore it.
• 2  Moderate = You often have problems concentrating, which is a source of distress to you.  This may affect your ability to work or play.  However, you are able to carry on a normal life with regard to daily activities.
• 3  Severe = You almost always experience problems with concentration.  Your quality of life is diminished.  You may have significant problems working or doing activities of daily living.  You have probably discussed this problem with a health professional.

"During the past 12 months, have you had problems with abnormal appetite which may be increased, decreased, or erratic?"

• 1  Mild = You sometimes notice that your appetite is not quite normal but don't consider it to be a serious problem.  You just ignore it.
• 2  Moderate = You often notice that your appetite is not normal and may have discussed this problem with a health professional.  The problem is somewhat annoying and you are concerned that something may be wrong with your digestive system.
• 3  Severe = You almost always experience abnormal appetite which may fluctuate between increased and decreased desire for food.  You find this very annoying or distressing and you have probably sought professional help in dealing with this problem.

• Difficulty thinking or remembering; absentminded; slow to react
• Involuntary or uncoordinated movements (tics, twitches, tremors)
• Difficulty walking or maintaining balance
• Incontinence or drooling
• Sensory system impairment (speech, hearing, taste, or smell)
• Conscious awareness of involuntary process - digestion, blood flow, etc.

"During the past 12 months, have you had difficulty thinking or remembering, absentmindedness, or slow reaction time?"

• 1  Mild = You sometimes experience one or more of these symptoms.  However, your performance is not greatly affected.  You ignore the symptom feeling that it is not a serious problem.
• 2  Moderate = You often experience one or more of these symptoms which is a source of concern for you because you feel that it does affect your functioning.  You may have discussed this problem with a health professional.  You may be receiving treatment or are taking a nutritional supplement for the condition.
• 3  Severe = You almost always experience one or more of these symptoms which is very distressing to you.  You have probably discussed this with a health professional and are probably taking some form of treatment because this problem does significantly affect your ability to function.  You quality of life is decreased as you have trouble doing some activities of daily living.

"During the past 12 months, have you had problems with involuntary or uncoordinated movements?"

• 1  Mild = You sometimes have a little problem in this area but you don't consider it serious and ignore it.
• 2  Moderate = You often have involuntary or uncoordinated movements which is a source of distress to you.  You have probably discussed this problem with a health professional.  You are able to function adequately with regard to work and recreation activities.
• 3  Severe = You almost always experience significant difficulty with these symptoms which is very distressing to you.  You have sought professional help and may be receiving treatment.  Your quality of life is diminished because you are unable to function normally in work or play activities.  You may also feel social stigma associated with this problem.

"During the past 12 months, have you had difficulty walking or maintaining balance?"

• 1  Mild = You sometimes experience some minor problems in this area, but do not consider it a serious enough condition to seek professional help.
• 2  Moderate = You often have problems with walking or maintaining balance which is a source of distress to you.  Your quality of life may be slightly affected, but you are able to perform basic activities which allow you to keep a job or have a relatively normal, active life.  You have sought professional assistance with this problem and may be receiving some form of treatment.
• 3  Severe = You almost always experience problems with walking or maintaining balance.  This is a serious problem which significantly diminishes your quality of life.  You may be partially or fully disabled.  You have sought professional help and are probably being treated for the condition.

"During the past 12 months, have you had problems with incontinence or drooling?"

• 1  Mild = You sometimes have minor problems in this area, but do not consider it serious enough to warrant professional assistance.
• 2  Moderate = You often experience problems with incontinence or drooling which is very distressing to you.  You may have sought professional help.  You are probably using some form of nonprescription remedy.
• 3  Severe = You almost always experience problems in this area and have sought professional help.  Your quality of life is diminished because you have to avoid awkward situations or limit your activities.

"During the past 12 months, have you had problems with sensory system impairment that causes dysfunction of speech, hearing, taste, or smell?"

• 1  Mild = You sometimes have minor problems which one or more of the senses.  You may be wearing glasses or contact lenses.
• 2  Moderate = You often experience problems with one or more of the senses which you find annoying or even distressing.  You may have sought professional help to improve sensory functioning or for symptomatic relief.
• 3  Severe = You almost always experience significant sensory system problems for which you have sought professional assistance.

"During the past 12 months, have you had problems with conscious awareness of involuntary processes such as digestion and blood flow?"

• 1  Mild = You sometimes become aware of involuntary processes which is strange but does not cause you significant distress.  It is mostly a strange, curious experience.
• 2  Moderate = You often become aware of involuntary processes which can be annoying or even distressing because you would rather have your consciousness focused on the outer world.
• 3  Severe = You are almost always aware of involuntary processes. Or, when you do become aware, the awareness is almost overwhelming.  For example, you may feel that you have to consciously direct food through the digestive process.  Or, you may feel that you have to consciously keep you heart beating.  This can provoke feelings of anxiety or panic.  You may feel as if you could die if you don't consciously keep your involuntary processes going.  You may have discussed these unusual experiences with a health professional.  You may have been referred to a counselor or psychotherapist to deal with this problem.

• History of seizures or convulsions
• Cool or cold spot on right side of abdomen
• Lapse or loss of consciousness
• Injury to tailbone or soreness of tailbone
• Constipation
• Abnormal mental and physical development
• Injury, pain or soreness on right side of abdomen below last rib

"Have you ever had seizures or convulsions?"

• 1  Mild = You have had one or two mild seizures or convulsions years ago.  You don't consider this to be a significant health issue.
• 2  Moderate = You have had numerous seizures or convulsions which have caused you distress.  These may have been recent or years ago.  The quality of your life is not now seriously affected.  You may be receiving treatment for this problem.
• 3  Severe = You have a history of serious problems with seizures or convulsions.  You have received medical treatment and your quality of life has been diminished by this condition.

"During the past 12 months, have you noticed a cool or cold spot on the right side of your abdomen?

• 1  Mild = You sometimes notice a little tendency for coolness on the right side of your abdomen.
• 2  Moderate = You often notice a distinct feeling of coolness on the right side of your abdomen.
• 3  Severe = You almost always sense coolness on the right side or your abdomen.  Or, at times a definite feeling of coldness is present in that area.

"During the past 12 months, have you experienced a lapse or loss of consciousness?"

• 1  Mild = You sometimes experience very brief episodes in which you think you might have lost consciousness.  This is a strange experience, but since it doesn't seem to affect your performance, you have not sought medical treatment.
• 2  Moderate = You often experience lapses or periods of lost consciousness which is a real concern to you.  You know this is not normal.  However, you are able to function in a regular way.  You have probably discussed this with a health professional and may be receiving some form of treatment.
• 3  Severe = You experience lapses or lost consciousness very often which is extremely distressing to you and diminishes your quality of life because you may not be able to safely do daily activities of living.  You have sought professional help and are probably receiving treatment.  You may have been diagnosed with a neurological conditions such as seizure disorder or narcolepsy.

"During the past 12 months, have you had a sore or painful tailbone or have your ever injured your tailbone?"

• 1  Mild = You sometimes notice a little soreness or tenderness at the base of your spine.  Or, you recall an injury to the tailbone.
• 2  Moderate = You often experience soreness, tenderness, or pain at the base of your spine.  Or, you recall a serious injury to your tailbone.
• 3  Severe = Your tailbone is almost always tender or sore.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"Have you had abnormal mental or physical development?"

• 1  Mild = You have had some mild abnormal development.
• 2  Moderate = You have had significant abnormal development but are able to live a relatively normal life.
• 3  Severe = You have had very serious abnormal development which has greatly diminished your quality of life.

"During the past 12 months, have you had pain or soreness on the right side of your abdomen below the last rib, or have you ever had an injury to this area?"

• 1  Mild = You sometime notice a little soreness or tenderness in this area.
• 2  Moderate = You often notice soreness or tenderness in this area.  Or, you recall an injury (such as a lick of blow) to this area.
• 3  Severe = You almost always experience soreness or pain in this area.  Or, when you do experience pain in this area it is very severe.

• Anger or hate
• Resentment, bitterness, or jealously
• Anxiety, worry, or fear
• Depression
• Hereditary predisposition for illness or prenatal condition

"During the past 12 months, have you experienced anger or hate?"

• 1  Mild = You sometimes experience anger or hate, but it is not excessive and you don't really consider it a problem.
• 2  Moderate = You often experience anger or hate which causes you distress.  You may have sought professional help for these feelings.
• 3  Severe = You experience frequent episodes of strong anger or hate.  You have probably sought professional help and have probably had significant interpersonal problems.

"During the past 12 months, have you experienced resentment, bitterness, or jealously?"

• 1  Mild = You sometimes experience these emotions but do not consider it to be a problem.
• 2  Moderate = You often experience these emotions and find it distressing.  You may have sought professional help.
• 3  Severe = You experience frequent episodes of these emotions which can be very powerful.  You have probably sought professional help.

"During the past 12 months, have you experienced anxiety, worry, or fear?"

• 1  Mild = You sometimes experience these emotions but do not consider it to be a problem.
• 2  Moderate = You often experience these emotions and find it distressing.  You may have sought professional help.
• 3  Severe = You experience frequent episodes of these emotions which can be very powerful.  You have probably sought professional help and are probably receiving treatment (psychotherapy and/or medication).  Your quality of life has been diminished because you feel limited or restricted in your options.

"During the past 12 months, have you had problems with depression?"

• 1  Mild = You sometimes feel a little depressed, but you carry on with your life and manage to do pretty well.  You have not talked with a health professional about it.
• 2  Moderate = You often feel depressed which is a significant problem for you.  You may have sought professional help for your depression.  You may be taking some form of treatment for it.  However, you are able to live a relatively normal life with little decrease to your quality of life because of depression.
• 3  Severe = You almost always feel depressed, or feel extremely depressed at times which significantly reduces your quality of life.  When you are depressed, you have great difficulty functioning.  You may be withdrawn or even suicidal.  You probably have sought and received professional help for this problem.

"Do you have a genetic or hereditary predisposition for certain illnesses or have you suffered from a prenatal condition."

• 1  Mild = You have relatives with the same condition that you have and the condition is thought to have a genetic aspect to it.  However, you don't feel that you have a serious health problem.
• 2  Moderate = There is a definite hereditary predisposition for illness which is affecting you.  However, the condition does not seriously diminish your quality of life.
• 3  Severe = You know that your have inherited a predisposition toward an illness from which are suffering.  Or, you are suffering the consequences of a prenatal condition (such as injury or disease while in the womb).  In other words, it would seem that you have been predestined to experience illness or disease.

• Sensory system impairment (speech, hearing, taste, or smell)
• Tiredness or fatigue
• Depression
• Constipation
• Thinning of hair or loss of body hair
• Underweight
• Splotches or blotches (white) on skin
• Dark circles under the eyes

"During the past 12 months, have you had problems with sensory system impairment that causes dysfunction of speech, hearing, taste, or smell?"

• 1  Mild = You sometimes have minor problems which one or more of the senses.  You may be wearing glasses or contact lenses.
• 2  Moderate = You often experience problems with one or more of the senses which you find annoying or even distressing.  You may have sought professional help to improve sensory functioning or for symptomatic relief.
• 3  Severe = You almost always experience significant sensory system problems for which you have sought professional assistance.

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you had problems with depression?"

• 1  Mild = You sometimes feel a little depressed, but you carry on with your life and manage to do pretty well.  You have not talked with a health professional about it.
• 2  Moderate = You often feel depressed which is a significant problem for you.  You may have sought professional help for your depression.  You may be taking some form of treatment for it.  However, you are able to live a relatively normal life with little decrease to your quality of life because of depression.
• 3  Severe = You almost always feel depressed, or feel extremely depressed at times which significantly reduces your quality of life.  When you are depressed, you have great difficulty functioning.  You may be withdrawn or even suicidal.  You probably have sought and received professional help for this problem.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you experienced thinning of hair or loss of body hair?"

• 1  Mild = You sometimes notice a tendency for thinning of hair or loss of body hair.
• 2  Moderate = You have experienced some hair loss which has caused you distress.
• 3  Severe = You have experienced significant hair loss which is a very serious problem for you.

"During the past 12 months, have you been underweight?"

• 1  Mild = You sometimes have a tendency to be underweight but you don't worry about it.
• 2  Moderate = You are often underweight and consider it to be enough of a problem to use nonprescription nutritional supplements or other treatments.
• 3  Severe = You are always underweight and you consider this to be a serious problem.  You have probably sought help from a health professional.

"During the past 12 months, have you had splotches or white blotches on your skin?"

• 1  Mild = You have noticed a slight tendency for this minor skin blemishes.  You ignore the problem.
• 2  Moderate =  You often have these blemishes which are a concern for you.  You may have sought help from a health professional.
• 3  Severe = You almost always have these blemishes.  You may find this problem very distressing.

"During the past 12 months, have you had dark circles under your eyes?"

• 1  Mild = You sometimes have dark circles under your eyes.
• 2  Moderate = You often notice these circles.
• 3  Severe = You almost always have dark circles which may be very annoying to you.

• Headache
• Abnormal blood pressure (high, low, or erratic)
• Abnormal pulse (quick, slow, or irregular)
• Fever or temperature at times without apparent cause
• Feeling of fullness in throat or face
• Hot and/or cold sensations (flushing)
• Abdominal pain or aching across lower portion of hips
• Kidney or bladder problems
• Constipation

"During the past 12 months, have you had problems with headache?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  Or the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you had problems with abnormal blood pressure (high, low, or erratic)?"

• 1  Mild = You sometimes have abnormal blood pressure.
• 2  Moderate = You often have abnormal blood pressure.  You have probably discussed this with a health professional.
• 3  Severe = You almost always suffer from abnormal blood pressure.  You are probably receiving treatment.

"During the past 12 months, have you experienced abnormal pulse (quick, slow, or irregular)?"

• 1  Mild = You sometimes have abnormal pulse.
• 2  Moderate = You often have abnormal pulse.  You have probably discussed this with a health professional.
• 3  Severe = You almost always have abnormal pulse.

"During the past 12 months, have you experienced fever or temperature at time without apparent cause?"

• 1  Mild = You sometimes experience a slight fever which may come and go without apparent cause.  In other words, you do not have an infection or other known cause of fever.
• 2  Moderate = You often experience fever or rise in temperature without apparent cause.
• 3  Severe = Almost every day, or at times during the day, you experience a fever.  You may have been diagnosed with chronic fatigue syndrome (CFS).

"During the past 12 months, have you experienced a feeling of fullness in your throat or face?"

• 1  Mild = You sometimes notice a feeling of fullness which may be strange or even uncomfortable.  However, you ignore this symptoms as not being serious enough to warrant treatment.
• 2  Moderate = You often experience this symptom which can be somewhat annoying or even distressing.  Because it is a rather vague sensation, you may have trouble describing it to a health professional.  You may have tried nonprescription remedies for symptomatic relief.

3  Severe = You almost always experience this sense of fullness which is very distressing.  You may at time feel a slight choking sensation because of this feeling of fullness.  You may have discussed this problem with a health professional.

"During the past 12 months, have you experienced hot and/or cold sensations (flushing)?"

• 1  Mild = You sometimes experience these sensations.
• 2  Moderate = You often experience these sensations.
• 3  Severe = Almost every day or at times during each day you experience these sensations.

"During the past 12 months, have you had problems with abdominal pain or aching across the lower portion of the hips?"

• 1  Mild = You sometimes experience these symptoms.
• 2  Moderate = You often experience these symptoms.
• 3  Severe = You almost always experience these symptoms.  Or, when you do experience them, they are extremely severe.

"During the past 12 months, have you had problems with kidney or bladder problems?"

• 1  Mild = You sometimes experience mild kidney problems such as excessive or decreased urination or mild irritation when urinating.  You have not sought medical treatment for this minor problem.
• 2  Moderate = You often experience kidney and bladder symptoms that are somewhat distressing.  You have sought assessment and/or treatment for this problem.  However, you are able to do any activity that you want and do not regard this as a major obstacle to having a high quality of life.
• 3  Severe = You almost always experience significant kidney and bladder problems that are very uncomfortable or painful (e.g., infection, inflammation, burning sensation during urination, etc.).  You probably have to adjust your daily activities such as work or play because of this problem.  You have sought assessment and/or treatment for this problem and regard it as a serious obstacle to high quality of life.

 "During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

Tiredness or fatigue
Heart palpitations or rapid pulse
Weakness
Shortness of breath
Fever or temperature at times without apparent cause
Underweight
Dizziness
Indigestion

"During the past 12 months, have you had problems with tiredness or fatigue?"

• 1  Mild = You sometimes feel tired or exhausted without having done a great deal of work or exercise.
• 2  Moderate = You often feel very tired or exhausted regardless of what activities you have been doing.  You have probably sought assessment or treatment for this problem.
• 3  Severe = You are almost always tired or exhausted or have been diagnosed with chronic fatigue syndrome (CFS).  You sleep a great deal or feel the need to rest often.  This decreases your ability to work and play and significantly lowers your quality of life.

"During the past 12 months, have you experienced heart palpitations or rapid pulse?"

• 1  Mild = You sometimes experience palpitations or rapid pulse..
• 2  Moderate = You often experience palpitations or rapid pulse.  You have probably discussed this with a health professional.
• 3  Severe = You almost always suffer from palpitations or rapid pulse. You are probably under treatment for this problem.

"During the past 12 months, have you suffered from general weakness?"

• 1  Mild = You sometimes experience general weakness.
• 2  Moderate = You often experience general weakness.
• 3  Severe = You almost always experience general weakness which is extremely debilitating.

"During the past 12 months, have you experienced shortness of breath?"

• 1  Mild = You sometimes experience shortness of breath.
• 2  Moderate = You often experience shortness of breath which is very distressing.  You have probably sought professional help for this problem.
• 3  Severe = You almost always experience shortness of breath and have sought professional help for this problem.

"During the past 12 months, have you experienced fever or temperature at time without apparent cause?"

• 1  Mild = You sometimes experience a slight fever which may come and go without apparent cause.  In other words, you do not have an infection or other known cause of fever.
• 2  Moderate = You often experience fever or rise in temperature without apparent cause.
• 3  Severe = Almost every day, or at times during the day, you experience a fever.  You may have been diagnosed with chronic fatigue syndrome (CFS).

"During the past 12 months, have you been underweight?"

• 1  Mild = You sometimes have a tendency to be underweight but you don't worry about it.
• 2  Moderate = You are often underweight and consider it to be enough of a problem to use nonprescription nutritional supplements or other treatments.
• 3  Severe = You are always underweight and you consider this to be a serious problem.  You have probably sought help from a health professional.

"During the past 12 months, have you had problems with dizziness?"

• 1  Mild = You sometimes experience mild dizziness which does not seem serious enough to warrant medical attention.
• 2  Moderate = You often experience dizziness which concerns you enough to seek professional help.  You may be taking some form of treatment for the problem.
• 3  Severe = Dizziness is a serious problem for you.  You have sought professional treatment and probably have adjusted your lifestyle to some extent to avoid dangerous or awkward situations.

"During the past 12 months, have you had problems with indigestion?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

History of irritable bowel syndrome or inflammatory bowel disease
History of intestinal flu
Mucous in stool
Diarrhea
Intestinal gas

"Have you ever had irritable bowel syndrome or inflammatory bowel disease?"

• 1  Mild = You have problems with such a condition which was mild and is no longer a source of significant distress.
• 2  Moderate = You have had chronic bowel problems but are able to live a relatively normal life with little decrease in the quality of your life.  You may be receiving treatment for this problem.
• 3  Severe = You have a history of serious problems with bowel disease and consider it to be a very serious problem.  You have received medical treatment and your quality of life has been diminished by this condition.

"Have you ever had intestinal flu?"

• 1  Mild = You had intestinal flu once but you recovered completely.
• 2  Moderate = You have had two or more episodes of intestinal flu with significant symptoms of diarrhea, constipation, abdominal pain, etc.
• 3  Severe = You have had two or more episodes of intestinal flu with significant symptoms which were slow to heal.  You may sense that your intestines have never fully recovered from the illness.

"During the past 12 months, have you noticed mucous in your stools?"

• 1  Mild = You sometimes notice a little mucous in your stools which you ignore.
• 2  Moderate = You often notice mucous in your stools which causes you some concern. You may have discussed this with a health professional.

3  Severe = You almost always notice mucous in your stools.  You have probably mentioned this to a health professional.

"During the past 12 months, have you had problems with diarrhea?"

• 1  Mild = You sometimes have minor problems with diarrhea or loose bowels.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with diarrhea which causes you significant concern.   You use some form of treatment for diarrhea, probably a nonprescription remedy.
• 3  Severe = You almost always have problems with diarrhea. You have sought help from a health professional and are engaged in some form of treatment.  You have probably been diagnosed with some form of bowel disease (such as IBS or inflammatory bowel disease).

"During the past 12 months, have you had problems with intestinal gas?"

• 1  Mild = You sometimes experience mild intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating in the intestines, or flatulence.
• 2  Moderate = You often experience intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

Pain along right rib cage, right shoulder or arm, or upper right back
Constipation
Nausea
Headaches, especially after eating
Fever
Intolerance to fats or greasy foods
Bad breath or bad taste in mouth not directly due to food or drink
Brown, yellow, or gray colored skin or brown splotches on skin
Dizziness
Abnormal pulse (quick, slow, or irregular)
Shortness of breath

"During the past 12 months, have you experienced pain along right rib cage, right shoulder or arm, or upper right back?"

• 1  Mild = You sometimes experience mild pain in one of these areas which you ignore.
• 2  Moderate = You often have pain or discomfort in one of these areas which is distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.  You may have been told that this is a common symptom for gallbladder problems.
• 3  Severe = You often have these pains which can be extremely distressing.  Or, the frequency of the episodes may not be great, but when you have them they are so painful that you essentially have to withdraw from life until the attack is over.   You have definitely sought professional treatment for this problem and may have been diagnosed as suffering from gallstones.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you had problems with nausea after eating?"

• 1  Mild = You sometimes experience nausea after eating but usually ignore it.
• 2  Moderate = You often experience nausea after eating which is quite distressing to you.  You probably avoid certain foods or take digestive aids to avoid this problem.
• 3  Severe = You almost always experience nausea after eating which is extremely distressing to you.  You probably have sought help from a health professional to relieve this problem.

"During the past 12 months, have you had problems with headaches, especially after eating?"

• 1  Mild = You sometimes have mild headaches which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have headaches which are quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have headaches which are extremely distressing and disabling.  You may have noticed that the headaches usually come after eating and seem to be linked to the digestive process.  Or, the frequency of the headaches may not be great, but when you have them they are so painful that you essentially have to withdraw from life.  This disrupts work and recreation and significantly lowers the quality of your life.  As an example, migraines would fall into this category.  You have definitely sought professional treatment for these severe headaches.

"During the past 12 months, have you experienced fever or temperature at times?"

• 1  Mild = You sometimes experience a slight fever which may come and go without apparent cause.  In other words, you do not have an infection or other known cause of fever.
• 2  Moderate = You often experience fever or rise in temperature.  You may have linked the fever to gallbladder dysfunction.  You may used a nonprescription remedy for symptomatic relief.
• 3  Severe = Almost every day, or at times during the day, you experience a fever.  Or, you have been diagnosed with cholecystitis and are aware that the fever is associated with inflammation of the gallbladder.

"During the past 12 months, have you experienced intolerance to fats or greasy foods?"

• 1  Mild = You sometimes experience a little gas, bloating, or abdominal pain after you have eaten fatty or greasy foods.  You ignore the problem.
• 2  Moderate =  You often experience unpleasantness after eating fatty or greasy foods.  You may avoid certain foods or take nonprescription remedies for this problem.
• 3  Severe = You almost always experience discomfort after eating these foods.  The pain may be very acute and focused on the upper right quadrant of the body.  You have probably discussed this problem with a health professional.  You have may been diagnosed as having gallstones.

"During the past 12 months, have you been bothered with bad breath or a bad taste in your mouth which is not directly due to food or drink."

• 1  Mild = You sometimes notice this symptom but ignore it or use mouth wash or such to cover it up.  The bad breath or bad taste is not directly due to specific food just eaten (such as onions or garlic).  The bad taste may be bitter.
• 2  Moderate = You often notice this symptom and find it annoying because it doesn't seem to be linked to anything that you have eaten (such as onions or garlic) which could account for it.  You may have been criticized by friends or family and may be somewhat sensitive to this issue.  Of course you are using mouthwash, mints or whatever which does not seem to addressing the cause of the problem.
• 3  Severe = You almost always notice this symptom and it is very distressing to the extent that you may avoid certain social situations or take extreme caution to avoid embarrassment.  Or the bad taste in your mouth is so annoying that you are concerned that you may have a dental or hygiene problem.

"During the past 12 months, have you had brown splotches on your skin or noticed a yellow, brown, or gray color to your skin which is not of racial origin?"

• 1  Mild = You have noticed a few splotches or a slight tendency for minor skin coloration.  You ignore the problem.
• 2  Moderate =  You often have these splotches which are a concern for you.  Or, you notice a definite tendency toward abnormal skin coloration.  You may have sought help from a health professional.
• 3  Severe = You almost always have these blemishes.  Or, your skin coloration is extremely pronounced.  You probably find this problem very distressing and have discussed it with a health professional.

"During the past 12 months, have you had problems with dizziness?"

• 1  Mild = You sometimes experience mild dizziness which does not seem serious enough to warrant medical attention.
• 2  Moderate = You often experience dizziness which concerns you enough to seek professional help.  You may be taking some form of treatment for the problem.
• 3  Severe = Dizziness is a serious problem for you.  You have sought professional treatment and probably have adjusted your lifestyle to some extent to avoid dangerous or awkward situations.

"During the past 12 months, have you experienced abnormal pulse (quick, slow, or irregular)?"

• 1  Mild = You sometimes have abnormal pulse.
• 2  Moderate = You often have abnormal pulse.  You have probably discussed this with a health professional.
• 3  Severe = You almost always have abnormal pulse.

"During the past 12 months, have you experienced shortness of breath?"

• 1  Mild = You sometimes experience shortness of breath.
• 2  Moderate = You often experience shortness of breath which is very distressing.  You have probably sought professional help for this problem.
• 3  Severe = You almost always experience shortness of breath and have sought professional help for this problem.

Shortness of breath
Cough
Feeling of heaviness, fullness or pain in lungs
Prone to congestion (head, throat or lungs)
Wheezing
Spit blood
Hay fever or other respiratory allergy

"During the past 12 months, have you experienced shortness of breath?"

• 1  Mild = You sometimes experience shortness of breath.
• 2  Moderate = You often experience shortness of breath which is very distressing.  You have probably sought professional help for this problem.
• 3  Severe = You almost always experience shortness of breath and have sought professional help for this problem.

"During the past 12 months, have you had problems with coughing?"

• 1  Mild = You sometimes cough a little which you ignore.
• 2  Moderate = You often cough and are using some form of treatment.
• 3  Severe = You almost always cough.  You have sought professional help and are being treated for this condition.

"During the past 12 months, have you experienced a feeling of heaviness, fullness or pain in the lungs?"

• 1  Mild = You sometimes experience such feelings which you ignore.
• 2  Moderate = You often have this experience which concerns you.  You may have discussed this problem with a health professional.
• 3  Severe = You almost always experience these feelings.  Or, when you do, the symptom is so distressing that you have sought professional help.  You may have been diagnosed with a respiratory illness.

"During the past 12 months, have you experienced congestion of the head, throat, or lungs?"

• 1  Mild = You sometimes experience congestion which you ignore.
• 2  Moderate = You often experience congestion and probably use a nonprescription remedy for symptomatic relief at times.
• 3  Severe = You almost always experience congestion which can be very distressing.  You have probably discussed this problem with a health professional.

"During the past 12 months, have you experienced shortness of breath?"

• 1  Mild = You sometimes experience a little wheezing which you ignore.
• 2  Moderate = You often experience wheezing which is distressing.  You have probably talked with a health professional about this problem.  However, you are able to do normal activities of daily living without serious problems.
• 3  Severe = You almost always experience wheezing.  Or, when you do have this problem it is so severe at to seriously impair your ability to do normal activities.  You have sought professional help for this distressing symptom.

"During the past 12 months, have you experienced hay fever or any other respiratory allergy?"

• 1  Mild = You sometimes have hay fever or some other respiratory allergy which you ignore because it is not a serious problem.
• 2  Moderate = You often experience these symptoms which can be distressing.  You may be using a nonprescription remedy for symptomatic relief.
• 3  Severe = You almost always experience these symptoms.  Or, when you do experience them they are so serious that you seek the help of a health professional.

Over or under-reactive to stimuli, or slow to react
Lack of discernment or insight
Poor concentration
Poor memory
Difficulty doing analysis or calculations
Irrationality or delusional thinking
Incoordination of movements or reflexes, or paralysis due to stroke
Hallucinations
Lack of self control

"During the past 12 months, have you noticed that you are over or under-reactive to stimuli, or slow to react?"

• 1  Mild = You sometimes have this problem, however, you simply ignore it or withdraw from the situation if it becomes too annoying.
• 2  Moderate = You are often aware that your reactions are abnormal. You find this distressing and seek relief with nonprescription remedies, or perhaps you have discussed this with a physician who has prescribed a medication for symptomatic relief.
• 3  Severe = You are almost always aware of being over or under-reactive to stimuli, or slow to react.  You have probably adapted your lifestyle to avoid awkward situations.  You have probably sought professional help for your problem.

"During the past 12 months, have you become aware that you may be lacking in discernment or insight?"

• 1  Mild = You sometimes have this problem, however, you simply ignore it or withdraw or avoid situation which require discernment or insight.  You don't feel that this really causes any decrease in the quality of your life.  It is a minor thing.
• 2  Moderate = You are often aware that your discernment or insight is inadequate. You find this distressing, or you become irritated because you feel that the problem is with other people who don't understand your perspective.  You may have sought counseling or psychotherapy to deal with this problem.
• 3  Severe = You almost always have problems with lack of discernment or insight.  This has been a major concern for you because you have made regretful decisions or actions that have been very costly to you or caused you great distress.  Or, you are often in situations where others make decisions for you because you don't understand what is going on.  You almost certainly have sought professional help for your problem.

"During the past 12 months, have you had problems with poor concentration?"

• 1  Mild = You sometimes have a little problem with concentration, but are able to function well enough that you don't consider it a serious problem.  You just ignore it.
• 2  Moderate = You often have problems concentrating, which is a source of distress to you.  This may affect your ability to work or play.  However, you are able to carry on a relatively normal life with regard to daily activities.
• 3  Severe = You almost always experience problems with concentration.  Your quality of life is diminished.  You may have significant problems working or doing activities of daily living.  You have probably discussed this problem with a health professional.

"During the past 12 months, have you had problems with poor memory?"

• 1  Mild = You sometimes have a little problem with poor memory, but are able to function well enough that you don't consider it a serious problem.  You just ignore it.
• 2  Moderate = You often have problems remembering, which is a source of distress to you.  This may affect your ability to work or play.  However, you are able to carry on a relatively normal life with regard to daily activities.

3  Severe = You almost always experience problems with poor memory.  Your quality of life is diminished.  You may have significant problems working or doing activities of daily living.  You have probably discussed this problem with a health professional.

"During the past 12 months, have you had difficulty doing analysis or calculations?"

• 1  Mild = You sometimes have a little problem with difficulty doing analysis or calculations, but are able to function well enough that you don't consider it a serious problem.  You just ignore it.
• 2  Moderate = You often have problems difficulty doing analysis or calculations, which is a source of distress to you.  This may affect your ability to work or play.  However, you are able to carry on a relatively normal life with regard to daily activities.
• 3  Severe = You almost always have difficulty doing analysis or calculations. Your quality of life is diminished.  You may have significant problems working or doing activities of daily living.  This problem has probably limited your vocational opportunities.  You have probably discussed this problem with a health professional.

"During the past 12 months, have you experienced irrationality or delusional thinking?"

• 1  Mild = You sometimes are aware that other people regard your way of thinking eccentric or highly unusual, and this may sometimes cause problems with other people.  But you figure it is just their problem because they don't think like you.  You just ignore it or get along as best you can.
• 2  Moderate = You often have problems in this area which can lead to significant difficulty in getting along with others, or you may feel that your thinking is somewhat our of touch with reality.  However, you are able to carry on a relatively normal life with regard to daily activities.  You may be receiving counseling or psychotherapy for this problem.
• 3  Severe = You almost always have difficulty with irrational or delusional thinking which is extremely disruptive or distressing.  Your quality of life is significantly diminished.  You may have significant problems working or doing activities of daily living.  You probably are receiving (or have received) professional help for this problem.  You may have been diagnosed with a psychiatric illness or feel that you are losing your mind.

"During the past 12 months, have you experienced incoordination of movements or reflexes, or paralysis due to stroke?"

• 1  Mild = You rarely have this kind of problem and it does not affect your ability to have a normal life.
• 2  Moderate = You sometimes have this kind of problem which can lead awkward or distressing situations, or minor disability with regard to specific activities of daily living.
• 3  Severe = You almost always have this kind of problem which is a major source of distress or disability.  You probably have significant problems working or doing activities of daily living.  You probably are receiving professional help (such as rehabilitation) for this problem.

"During the past 12 months, have you experienced hallucinations?"

• 1  Mild = You rarely perceive things that other people are not aware of, but you just ignore it or figure that it is a mystical experience associated with spiritual growth.  Hallucinations involve sensory phenomena such as "hearing voices" or "seeing" things that others do not perceive.
• 2  Moderate = You sometimes have hallucinations which can lead to significant difficulty in getting along with others, or you may feel distressed because you are "out of touch with reality."  However, you are able to carry on a relatively normal life with regard to daily activities.  You may be receiving therapy for this problem.
• 3  Severe = You almost always have difficulty with hallucinations which is extremely disruptive or distressing.  Your quality of life is significantly diminished.  You may have significant problems working or doing activities of daily living.  You probably are receiving (or have received) professional help for this problem.  You may have been diagnosed with a psychiatric illness or feel that you are losing your mind.

"During the past 12 months, have you experienced problems with lack of self control?"

• 1  Mild = You occasionally notice that you feel a little "out of control" which is somewhat distressing or annoying, but are able to compensate and live a relatively normal life without professional help.
• 2  Moderate = You sometimes have this kind of problem, or when you do it is quite awkward or distressing.  You may feel shame or blame about not being able to control your thoughts, feelings or behaviors.  You have probably received professional help such as counseling or psychotherapy, but are able to have a relatively high quality of life.

3  Severe = You almost always feel out of control, or when you do, it is very disruptive.  You probably have significant problems working or doing activities of daily living, or maintaining normal relationships.  You almost certainly are receiving professional help, which may be intensive at times.

Slow pulse
Rapid pulse
Palpitation or throbbing of heart
Low blood pressure
High blood pressure
Erratic blood pressure (sometimes high, sometimes low)
Chest pain (angina) or feeling of fullness around heart
Fluttering of heart

"During the past 12 months, have you experienced slow pulse?"

• 1  Mild = You sometime notice that your pulse is a little slow but you ignore it because it doesn't seem to be a serious problem.
• 2  Moderate = You often experience a notably slow pulse which concerns you to the extent that you have discussed this problem with a health professional and may be receiving treatment for the condition.
• 3  Severe = You almost always experience extremely slow pulse which is very distressing to you.  You have definitely sought help from a health professional because this seems to indicate that something is wrong with your cardiovascular system.

"During the past 12 months, have you experienced fast pulse?"

• 1  Mild = You sometime notice that your pulse is a little fast but you ignore it because it doesn't seem to be a serious problem.
• 2  Moderate = You often experience rapid pulse which concerns you to the extent that you have discussed this problem with a health professional and may be receiving treatment for the condition.
• 3  Severe = You almost always experience rapid pulse which is very distressing to you.  You have definitely sought help from a health professional because this seems to indicate that something is wrong with your cardiovascular system.

"During the past 12 months, have you experienced heart palpitations or throbbing of heart?"

• 1  Mild = You sometimes experience palpitations or throbbing of heart.
• 2  Moderate = You often experience palpitations or throbbing of heart.  You have probably discussed this with a health professional.
• 3  Severe = You almost always suffer from palpitations or throbbing of heart. You are probably under treatment for this problem.

"During the past 12 months, have you had problems with low blood pressure?"

• 1  Mild = You sometimes have low blood pressure.
• 2  Moderate = You often have low blood pressure.
• 3  Severe = You almost always have low blood pressure.

"During the past 12 months, have you had problems with high blood pressure?"

• 1  Mild = You sometimes have high blood pressure.
• 2  Moderate = You often have high blood pressure.
• 3  Severe = You almost always have high blood pressure.

"During the past 12 months, have you had problems with erratic blood pressure (sometimes high, sometimes low)?"

• 1  Mild = You sometimes have erratic blood pressure.
• 2  Moderate = You often have erratic blood pressure.  You have probably discussed this with a health professional.
• 3  Severe = You almost always suffer from erratic blood pressure.  You are probably receiving treatment for this problem.

"During the past 12 months, have you had problems with chest pain (angina) or feeling of fullness around heart?"

• 1  Mild = You sometimes experience mild chest pain (angina) or feeling of fullness around heart.
• 2  Moderate = You often experience chest pain (angina) or feeling of fullness around heart, or when you do experience it, it is quite distressing.  You have probably discussed this with a health professional.

3  Severe = You almost always suffer chest pain (angina) or feeling of fullness around heart, or when you do experience it, it  is extremely distressing.  You are almost certainly receiving treatment for this problem.

"During the past 12 months, have you experienced the sensation of "fluttering heart?"

• 1  Mild = You sometimes experience a sensation of "fluttering heart" which is mildly distressing but you are not being treated for this symptom.
• 2  Moderate = You often experience "fluttering heart" or when you do it is quite distressing. You have probably discussed this with a health professional.
• 3  Severe = You often experience "fluttering heart" and it is extremely distressing. You are almost certainly receiving treatment for this problem.

Indigestion 1 to 3 hours after eating
Intestinal gas
Constipation
Diarrhea
Mucous in stools

"During the past 12 months, have you had problems with indigestion 1 to 3 hours after eating?"

• 1  Mild = You sometimes experience an uncomfortable feeling after eating but ignore it.
• 2  Moderate = You often experience significant indigestion 1 to 3 hours after eating which is distressing.  You are probably taking digestive aids or avoiding certain foods.
• 3  Severe = You almost always experience notable indigestion 1 to 3 hours after eating which may culminate in stomach pain.  You have probably sought help for this problem from a health professional.

"During the past 12 months, have you had problems with intestinal gas?"

• 1  Mild = You sometimes experience mild intestinal gas which you ignore.  The gas may manifest as a feeling of fullness or bloating with excessive flatulence.
• 2  Moderate = You often experience intestinal gas which is distressing and causes you to avoid certain foods or otherwise adjust your lifestyle.  You may be taking some form of nonprescription dietary aid to reduce gas.
• 3  Severe = You almost always experience intestinal gas which is very distressing and may be physically painful.  You have probably tried various remedies and may have discussed the problem with a health professional.  This symptom is a source of considerable misery to you.

"During the past 12 months, have you had problems with constipation?"

• 1  Mild = You sometimes have minor problems with constipation but never go more than 2 days without having a bowel movement.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with constipation, sometimes with periods of three or more days without a bowel movement.  You use some form of treatment for constipation.  Bowel movements are often unpleasant or painful.
• 3  Severe = You almost always have problems with constipation.  Bowel movements are extremely difficult.  Fecal matter is usually dry and hard.  In some conditions (such as inflammatory bowel disease), constipation may alternate with diarrhea.

"During the past 12 months, have you had problems with diarrhea?"

• 1  Mild = You sometimes have minor problems with diarrhea or loose bowels.  You don't consider this a serious problem and do not treat the condition.
• 2  Moderate = You often have problems with diarrhea which causes you significant concern.   You use some form of treatment for diarrhea, probably a nonprescription remedy.
• 3  Severe = You almost always have problems with diarrhea. You have sought help from a health professional and are engaged in some form of treatment.

"During the past 12 months, have you noticed mucous in your stools?"

• 1  Mild = You sometimes notice a little mucous in your stools which you ignore.
• 2  Moderate = You often notice mucous in your stools which causes you some concern. You may have discussed this with a health professional.
• 3  Severe = You almost always notice mucous in your stools.  You have probably mentioned this to a health professional.

Excess sugar in urine (sweet smelling urine or high urine test)
Urination is frequent, excessive, or scant
Wounds heal slowly
Kidney or bladder problems
Impaired or distorted vision

"During the past 12 months, have you noticed excess sugar in your urine?"

• 1  Mild = You have rarely noticed this tendency and are not particularly concerned about it.
• 2  Moderate = You often noticed this which does concern you.  You have probably discussed this with a health professional and may be receiving treatment or taking precautions to avoid the problem.
• 3  Severe = You almost always have this problem, or when you do it is severe.  You have almost certainly discussed this with a health professional and may be receiving treatment for the condition.  You are probably monitoring your urine for sugar under a physician's supervision.

"During the past 12 months, have you had problems with frequent, excessive, or scant urination?"

• 1  Mild = You sometimes experience frequent, excessive, or scant urination, but are not particularly concerned about it.
• 2  Moderate = You often notice frequent, excessive, or scant urination which does somewhat concern you.  You may have discussed this with a health professional.  You may be taking simple precautions to avoid this tendency.
• 3  Severe = You almost always experience frequent, excessive, or scant urination, or when you do it is extreme.  You are very concerned about it.  You have probably discussed this with a health professional and may be receiving treatment for the condition.

"During the past 12 months, have you noticed that wound heal slowly?"

• 1  Mild = You sometimes notice that wounds heal slowly.  Since it doesn't seem to affect you otherwise, you are not very concerned about this tendency.
• 2  Moderate = You often noticed that you are prone to slow wound healing.  This is a concern to you.  You may have discussed it with a health professional.
• 3  Severe = Wounds almost always heal slowly. You have probably discussed this with a health professional and take it into consideration when requiring treatment such as surgery.  You take special precautions to avoid injury or illness because of this problem.

"During the past 12 months, have you had problems with kidney or bladder problems?"

• 1  Mild = You sometimes experience mild kidney problems such as excessive or decreased urination or mild irritation when urinating.  You have not sought medical treatment for this minor problem.
• 2  Moderate = You often experience kidney and bladder symptoms that are somewhat distressing.  You have sought assessment and/or treatment for this problem.  However, you are able to do any activity that you want and do not regard this as a major obstacle to having a high quality of life.
• 3  Severe = You almost always experience significant kidney and bladder problems that are very uncomfortable or painful (e.g., infection, inflammation, burning sensation during urination, etc.).  You probably have to adjust your daily activities such as work or play because of this problem.  You have sought assessment and/or treatment for this problem and regard it as a serious obstacle to high quality of life.

"During the past 12 months, have you had problems with your vision?"

• 1  Mild = You have lost some of this sense or it has become distorted.  If you where glasses or contacts, this is at least a mild symptom.
• 2  Moderate = You often notice that your vision is distorted (whether you are wearing glasses/contacts or not).  This distortion may come and go erratically.  Or, your vision has become progressively worse requiring stronger prescriptions or other interventions.
• 3  Severe = You almost always experience significant visual problems requiring professional treatment.  You vision remains somewhat impaired or distorted despite appropriate treatment.  You may have to adjust your daily activities accordingly.  The quality of your life is diminished.

Pain or discomfort on left side of abdomen
Low blood pressure
Rapid pulse
Nausea
Highly suggestible or overly imaginative
Mood swings or emotional upsets

"During the past 12 months, have you been bothered by pain or discomfort on the left side of your abdomen?"

• 1  Mild = You sometimes notice a little discomfort in this area but ignore it because it doesn't seem serious enough to warrant attention.
• 2  Moderate = You are often aware of this symptom or when it occurs it is distressing enough for you to seek some form of symptomatic relief.  You may have discussed this problem with a health professional.
• 3  Severe = You are almost always aware of pain or discomfort on the left side of your abdomen which is quite distressing.  You have probably sought symptomatic relief and have likely discussed this symptom with a health professional.

"During the past 12 months, have you had problems with low blood pressure?"

• 1  Mild = You sometimes have low blood pressure.
• 2  Moderate = You often have low blood pressure.
• 3  Severe = You almost always have low blood pressure.

"During the past 12 months, have you experienced fast pulse?"

• 1  Mild = You sometime notice that your pulse is a little fast but you ignore it because it doesn't seem to be a serious problem.
• 2  Moderate = You often experience rapid pulse which concerns you to the extent that you have discussed this problem with a health professional and may be receiving treatment for the condition.
• 3  Severe = You almost always experience rapid pulse which is very distressing to you.  You have definitely sought help from a health professional because this seems to indicate that something is wrong with your cardiovascular system.

"During the past 12 months, have you had problems with nausea?"

• 1  Mild = You sometimes experience nausea but usually ignore it.
• 2  Moderate = You often experience nausea which is quite distressing to you.  You probably avoid certain foods or take digestive aids to avoid this problem.

3  Severe = You almost always experience nausea which is extremely distressing to you.  You probably have sought help from a health professional to relieve this problem.

"During the past 12 months, have you noticed that you are highly suggestible or overly imaginative?"

• 1  Mild = You sometimes feel that you are easily influenced by others or that your imagination runs away with itself, but since this doesn't seem to cause any problems, you are not concerned about it.
• 2  Moderate = You typically feel that you are highly suggestible or that your imagination is very strong. This may at times cause some problems because you are so easily influenced by others, or because your imagination causes you to become troubled.
• 3  Severe = You are easily influenced by others or by the circumstances of life, perhaps to the point of not feeling in control of your own life.  Or, you may feel that your imagination gets you into trouble because others perceive you as being unrealistic or out of touch.  You may have talked to a therapists or other health professional about this problem.

"During the past 12 months, have you had problems with mood swings or emotional upsets?"

• 1  Mild = You sometimes experience mood swings or emotional upsets, but you carry on with your life and manage to do pretty well.  You have not talked with a health professional about it.
• 2  Moderate = You often have mood swings or emotional upsets, or when you do it is quite distressing. You may have sought professional help for this problem.  You may be taking some form of treatment for it.  However, you are able to live a relatively normal life with little decrease to your quality of life.
• 3  Severe = You almost always have this kind of problem, or when you do it is extreme, which significantly reduces your quality of life.  Because of this problem, you have great difficulty functioning.  You probably have sought and received professional help for this problem.

Infertility
Abnormal sex drive (high, low, or absent)
Menstrual or menopausal problems (female)
Prostate problems or impotence (male)
Pelvic pain or discomfort

"During the past 12 months, have you had problems with infertility?"

• 1  Mild = You want to have a child but, but despite numerous attempts, have not succeeded.  You have not talked with a health professional about this as you feel that you will eventually succeed.
• 2  Moderate = You have talked with a health professional about this problem, but have been told that there is no biological reason for infertility.  Yet, you are still concerned that you may be infertile.  You may be receiving treatment for infertility with hopes that you will become fertile.
• 3  Severe = Infertility is a very serious concern to you.  You have sought professional help and medical treatment for this problem over a period of years.

"During the past 12 months, have you had problems with abnormal sex drive (high, low, or absent)?"

• 1  Mild = You rarely have an abnormal sex drive, and when you do, you consider it to be a minor problem.
• 2  Moderate = You have talked with a health professional about this problem, and may be receiving treatment.
• 3  Severe = This is a chronic or severe problem for you.  You have sought professional help and have probably received treatment for this problem within the past year.

"During the past 12 months, have you had menstrual or menopausal problems?"

• 1  Mild = You rarely have symptoms in this area, and when you do, you consider it to be a minor problem that you can deal with yourself.
• 2  Moderate = You have talked with a health professional about this problem, and may be receiving treatment.  However, you are able to have a high quality of life.
• 3  Severe = This is a chronic or severe problem for you.  You have sought professional help and have probably received treatment for this problem within the past year.

"During the past 12 months, have you had prostate problems or impotence?"

• 1  Mild = You rarely have this kind of problem, and when you do, you consider it to be a minor inconvenience
• 2  Moderate = You have talked with a health professional about this problem, and may be receiving treatment.
• 3  Severe = This is a chronic or severe problem for you.  You have sought professional help and have probably received treatment for this problem within the past year.

"During the past 12 months, have you experienced pelvic pain or discomfort?"

• 1  Mild = You sometimes have mild pelvic pain or discomfort which you ignore.  You might take an aspirin or mild nonprescription pain reliever for symptomatic relief.
• 2  Moderate = You often have pelvic pain or discomfort which is quite distressing to you.  You have probably discussed this with a health professional and may have a prescription for use during acute episodes.
• 3  Severe = You often have pelvic pain or discomfort, or when you do it is extremely distressing and disabling.  This disrupts work and recreation and significantly lowers the quality of your life.  You have sought professional treatment for pelvic pain or discomfort