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. | | 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 | |