Read the following questions and select the number that applies. 

KEY:     Leave blank (0) = Do not consume or use

1 = Consume or use 2-3 times/month

2 = Consume or use weekly

3 = Consume or use daily

NOTE: If 0, leave blank for all selections in this questionnaire..

Medications: Indicate any medicines you’re currently taking or have taken in the last 12 months (0 = no, 2 = yes):

Read the following questions for each section and select the number that applies. 

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur 

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

KEY:       Leave blank (0) = No or Do not have the symptom, the symptom does not occur

1 = Yes or It is a minor or mild symptom or it rarely occurs (once a month or less)

2 = It is a moderate symptom or it occasionally occurs (weekly)

3 = It is a severe symptom or it frequently occurs (daily)

By completing this questionnaire, I acknowledge the following:

1. Accuracy of Information: I confirm that all information provided is accurate and true to the best of my knowledge.
2. Purpose of Questionnaire: I understand that this questionnaire is for assessment purposes only and does not establish a practitioner-client relationship or any commitment to work together.
3. Non-Substitute for Medical Advice: I recognize that any insights or recommendations provided are for informational purposes and are not a replacement for medical advice from a qualified healthcare provider.
4. Personalized Guidance: I understand that any guidance received is tailored to my individual answers and may not apply to others.