| Section B: Major Symptoms | ||
| Instructions: For each symptom that is present, enter the appropriate number in the Point Score Column. If a symptom is occasional or mild…………….....………score 3 points. If a symptom is frequent and/or moderately severe….....score 6 points. If a symptom is severe and/or disabling….……………...score 9 points. Total the score for this section and record it in the box at the end of this section. | ||
| | | Point Score |
| 1. | Fatigue or lethargy | 3 / 6 / 9 |
| 2. | Feeling of being "drained" | 3 / 6 / 9 |
| 3. | Poor memory | 3 / 6 / 9 |
| 4. | Feeling "spacey" or "unreal" | 3 / 6 / 9 |
| 5. | Depression | 3 / 6 / 9 |
| 6. | Numbness, burning or tingling | 3 / 6 / 9 |
| 7. | Insomnia | 3 / 6 / 9 |
| 8. | Muscle aches | 3 / 6 / 9 |
| 9. | Muscle weakness or paralysis | 3 / 6 / 9 |
| 10. | Joint pain or swelling | 3 / 6 / 9 |
| 11. | Abdominal pain | 3 / 6 / 9 |
| 12. | Constipation | 3 / 6 / 9 |
| 13. | | 3 / 6 / 9 |
| 14. | Bloating, belching or intestinal gas | 3 / 6 / 9 |
| 15. | Troublesome vaginal burning, itching or discharge | 3 / 6 / 9 |
| 16. | Prostatitis | 3 / 6 / 9 |
| 17. | Impotence | 3 / 6 / 9 |
| 18. | Loss of sexual desire or feeling | 3 / 6 / 9 |
| 19. | Endometriosis or infertility | 3 / 6 / 9 |
| 20. | Cramps and/or other menstrual irregularities | 3 / 6 / 9 |
| 21. | Premenstrual tension | 3 / 6 / 9 |
| 22. | Attacks of anxiety or crying | 3 / 6 / 9 |
| 23. | Cold hands or feet and/or chilliness | 3 / 6 / 9 |
| 24. | Shaking or irritable when hungry | 3 / 6 / 9 |
| | Total Score – Section B | |
Continue to Section C - Other Symptoms
