Symptoms Rating Chart
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1
2SYMPTOMS RATING CHART: FEMALE
Client Name ______________________________________
Date 1: _____________________________
Date 2: _____________________________
Please rate symptoms from 0 to 5:
Date 3: _____________________________
0 = symptom is not present
3 = symptom is mild - moderate
1 = symptom is rare
4 = symptom is moderate - severe
2 = symptom is mild
5 = symptom is severe
Subjective Symptoms
RATING
RATING
RATING
InE
DeE
InP
DeP
InT
DeT
InD
DeD
InC
DeC
InI
DeTh
Acne
X
X
X
X
X
Anxiety/Nervousness
X
X
X
X
X
Apathy
X
X
X
X
Breast Tenderness
X
X
X
X
Brittle Nails
X
Burned Out Feeling
X
X
X
X
X
Chemical Sensitivities
X
X
Cold Body Temperature
X
X
X
Cold Extremities
X
X
X
X
Confusion
X
X
X
X
Constipation
X
X
X
Cramping Abdominal
X
X
X
Cravings for Sweet
X
X
X
Decreased Concentration
X
X
X
X
X
X
Decreased Sex Drive
X
X
X
X
X
X
X
Decreased Sexual Sensation
X
X
X
X
X
X
Decreased Stamina
X
X
X
X
Deepening of Voice
X
X
X
X
Depressed Mood
X
X
X
X
X
X
X
Dry Eyes
X
X
X
Dry Skin/Hair
X
X
X
X
Fatigue
X
X
X
X
X
Fibrocystic Breasts
X
X
X
Telephone: (250) 590-5787
•
E-mail: wellness@agelessliving.ca
•
Website:
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Parent category: Life