Weekly Symptom Checklist For Children Template Page 3
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3LUNGS
________
Coughing
________
Sneezing
________
Difficulty breathing
________
Wheezing
Total ________
DIGESTIVE TRACT ________
Nausea
________
Vomiting
________
Diarrhea
________
Constipation
________
Bloated feeling
________
Belching
________
Passing gas (flatulence)
________
Heartburn
________
Tummy ache
________
Poor appetite
________
Refusal to eat
Total ________
JOINTS/MUSCLE
________
Coordination problems
________
Pain in muscles (e.g., leg ache)
________
Pain in joints ( e.g., knee ache)
Total ________
ENERGY
________
Fatigue, sluggishness
________
Apathy, lethargy
________
Hyperactivity
________
Restlessness
________
Sleeping problems
Total ________
MIND/EMOTIONS
________
Inattentiveness or poor concentration
________
Mood swings
________
Anxiety, nervousness
________
Fear
________
Anger
________
Irritability
________
Aggressiveness (e.g. hitting, kicking, biting)
________
Crying or weepiness
________
Tantrums
________
Hyperactivity
Total ________
OTHER
________
Frequent urination
________
Itching of anus or genitals
________
Bed wetting
________
Wetting or soiling of clothes
Total ________
TOTAL _________
GRAND TOTAL
Fenske Holistic Healthcare Center
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Weekly Symptom Checklist
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Parent category: Life