Section C: Other 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 persistent………………...score 9 points.

Total the score for this section and record it in the box at the end of this section.

Point Score

1.

Drowsiness

3 / 6 / 9

2.

Irritability or jitteriness

3 / 6 / 9

3.

Uncoordinated

3 / 6 / 9

4.

Inability to concentrate

3 / 6 / 9

5.

Frequent mood swings

3 / 6 / 9

6.

Headache

3 / 6 / 9

7.

Dizziness/loss of balance

3 / 6 / 9

8.

Pressure above ears, feeling of head swelling/tingling

3 / 6 / 9

9.

Tendency to bruise easily

3 / 6 / 9

10.

Chronic rashes or itching

3 / 6 / 9

11.

Psoriasis or recurrent hives

3 / 6 / 9

12.

Indigestion or heartburn

3 / 6 / 9

13.

Food sensitivity or intolerance

3 / 6 / 9

14.

Mucus in stools

3 / 6 / 9

15.

Hemorrhoids or rectal itching

3 / 6 / 9

16.

Dry Mouth or throat

3 / 6 / 9

17.

Rash or blisters in mouth

3 / 6 / 9

18.

Bad breath

3 / 6 / 9

19.

Foot, hair or body odor not relieved by washing

3 / 6 / 9

20.

Nasal congestion, discharge or post nasal drip

3 / 6 / 9

21.

Nasal itching

3 / 6 / 9

22.

Sore or dry throat

3 / 6 / 9

23.

Laryngitis, loss of voice

3 / 6 / 9

24.

Cough or recurrent bronchitis

3 / 6 / 9

25.

Pain or tightness in chest

3 / 6 / 9

26.

Wheezing or shortness of breath

3 / 6 / 9

27.

Urgency frequency, urgency or incontinence

3 / 6 / 9

28.

Burning on urination

3 / 6 / 9

29.

Spots in front of eyes or erratic vision

3 / 6 / 9

30.

Burning or tearing of eyes

3 / 6 / 9

31.

Recurrent infections or fluid in ears

3 / 6 / 9

32.

Ear pain or deafness

3 / 6 / 9

Total Score – Section C