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Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 1 of 10
SYMPTOM TRACKER
Rate how often you experience each of the following symptoms using the following frequency scale:
0 = never 1 = monthly 2 = weekly 3 = daily
GENERAL 0 1 2 3 0 1 2 3
β β β β Fever
β β β β Chills/Cold all over
β β β β Cold intolerance
β β β β Aches/Pains
β β β β General weakness
β β β β Difficulty sweating
β β β β Excessive sweating
β β β β Heat intolerance
β β β β Swollen glands
β β β β Cold hands & feet
β β β β Low blood pressure
β β β β Distorted vision
EARS 0 1 2 3 0 1 2 3
β β β β Aches
β β β β Discharge
β β β β Pains
β β β β Ringing
β β β β Deafness/Hearing loss
β β β β Feeling of fullness
β β β β Itching
β β β β Pressure
β β β β Frequent infections
β β β β Tubes in ears
β β β β Sensitive to loud noises
β β β β Hearing hallucinations
THROAT 0 1 2 3 0 1 2 3
β β β β Mucus
β β β β Difficulty swallowing
β β β β Frequent hoarseness
β β β β Tonsillitis
β β β β Enlarged glands
β β β β Constant clearing of throat
β β β β Throat closes up
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 2 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
HEAD 0 1 2 3 0 1 2 3
β β β β Headaches after meals
β β β β Headaches if meals skipped
β β β β Headaches severe
β β β β Headaches migraine
β β β β Headaches frontal
β β β β Occipital (back of head) aches
β β β β Piercing headaches
β β β β Afternoon headaches
β β β β Daytime headaches
β β β β Headaches relieved by eating sweets
β β β β Face twitch or ticks
EYES 0 1 2 3 0 1 2 3
β β β β Feeling of sand in eyes
β β β β Double vision
β β β β Blurred vision
β β β β Poor night vision
β β β β See bright flashes
β β β β Halo around lights
β β β β Eye pains
β β β β Floaters in eyes
β β β β Puffiness under eyes
β β β β Strong light irritates
β β β β Cataracts
β β β β Visual hallucinations
β β β β Conjunctivitis
β β β β Eye crusting
NECK 0 1 2 3 0 1 2 3
β β β β Stuffy
β β β β Stiffness
β β β β Swelling
β β β β Lumps
β β β β Neck glands swell
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 3 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
SKIN/HAIR/NAILS 0 1 2 3 0 1 2 3
β β β β Cuts heal slowly
β β β β Bruise easily
β β β β Rashes
β β β β Pigmentation
β β β β Changing moles
β β β β Calluses
β β β β Eczema
β β β β Psoriasis
β β β β Dryness/cracking skin
β β β β Oiliness
β β β β Itching
β β β β Acne
β β β β Boils
β β β β Hives
β β β β Fungus on nails
β β β β Hair loss
β β β β Peeling skin
β β β β Shingles
β β β β Nails split
β β β β Fingernails chip, break or peel
β β β β White spots/Lines on nails
β β β β Crawling sensation
β β β β Burning on bottom of feet
β β β β Athletes foot
β β β β Cellulite
β β β β Circles under eyes
β β β β Bugs love to bite you
Is your skin sensitive to:
β β β β Sun?
β β β β Fabrics?
β β β β Detergents?
β β β β Lotions & creams?
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 4 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
NOSE/SINUSES 0 1 2 3 0 1 2 3
β β β β Stuffy
β β β β Bleeding
β β β β Running/Discharge
β β β β Watery nose
β β β β Congested
β β β β Infection
β β β β Polyps
β β β β Acute smell
β β β β Drainage
β β β β Sneezing spells
β β β β Post nasal drip
β β β β No sense of smell
β β β β Change of seasons tend to make your symptoms worse
If yes, is it worse in the:
β β β β Spring?
β β β β Summer?
β β β β Fall?
β β β β Winter?
MOUTH 0 1 2 3 0 1 2 3
β β β β Coated tongue
β β β β Sore tongue
β β β β Dental problems
β β β β Bleeding gums
β β β β Canker sores
β β β β TMJ
β β β β Cracked lips/corners
β β β β Chapped lips
β β β β Fever blisters
β β β β Wear dentures
β β β β Grind teeth when sleeping
β β β β Bad breath
β β β β Dry mouth
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 5 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
CIRCULATION/RESPIRATION 0 1 2 3 0 1 2 3
β β β β Swollen ankles
β β β β Sensitive to hot
β β β β Sensitive to cold
β β β β Extremities cold or clammy
β β β β Hands/Feet go to sleep/numbness/tingling
β β β β High Blood Pressure
β β β β Chest pain
β β β β Pain between shoulders
β β β β Dizziness upon standing
β β β β Fainting spells
β β β β High cholesterol
β β β β High triglycerides
β β β β Wheezing
β β β β Irregular heartbeat
β β β β Palpitations
β β β β Low exercise tolerance
β β β β Frequent coughs
β β β β Breathing heavily
β β β β Frequently sighing
β β β β Shortness of breath
β β β β Night sweats
β β β β Varicose veins/spider veins
β β β β Mitral valve prolapse
β β β β Murmurs
β β β β Skipped heartbeat
β β β β Heart enlargement
β β β β Angina pain
β β β β Bronchitis/Pneumonia
β β β β Emphysema
β β β β Croup
β β β β Frequent colds
β β β β Heavy/tight chest
β β β β Phlebitis
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 6 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
GASTROINTESTINAL 0 1 2 3 0 1 2 3
β β β β Peptic/Duodenal Ulcer
β β β β Poor appetite
β β β β Excessive appetite
β β β β Gallstones
β β β β Gallbladder pain
β β β β Liver pain
β β β β Nervous stomach
β β β β Full feeling after small meal
β β β β Indigestion
β β β β Heartburn
β β β β Acid Reflux
β β β β Hiatal Hernia
β β β β Nausea
β β β β Vomiting
β β β β Vomiting blood
β β β β Abdominal Pains/Cramps
β β β β Loss of taste for meat
β β β β Feeling of incomplete bowel evacuation
β β β β Gas
β β β β Diarrhea
β β β β Constipation
β β β β Changes in bowels
β β β β Rectal bleeding
β β β β Tar-like stools
β β β β Rectal itching
β β β β Bloating
β β β β Belch frequently
β β β β Anal itching
β β β β Anal fissures
β β β β Bloody stools
β β β β Pale yellow/tan/gray stools
β β β β Green stools
β β β β Mucus in stool
β β β β Undigested food in stools
β β β β Bad breath
β β β β Stomach upset taking vitamins
β β β β Anemia unresponsive to iron
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 7 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
KIDNEY/URINARY TRACT 0 1 2 3 0 1 2 3
β β β β Burning
β β β β Frequent urination
β β β β Blood in urine
β β β β Night time urination
β β β β Problem passing urine
β β β β Kidney pain
β β β β Kidney stones
β β β β Painful urination
β β β β Bladder infections
β β β β Kidney infections
β β β β Bedwetting
β β β β Pain in mid back region
β β β β Incontinence or loss of bladder control
JOINTS/MUSCLES/TENDONS 0 1 2 3 0 1 2 3
β β β β Pain wakes you
β β β β Muscle twitches
β β β β Weakness in legs and arms
β β β β Balance problems
β β β β Muscle cramping
β β β β Foot cramps
β β β β Pain in tendons
β β β β Joint issues
β β β β Spasms
β β β β Head injury
β β β β Muscle stiffness in morning
β β β β Damp weather bothers you
β β β β Pain in mid back region
β β β β Restless leg syndrome
β β β β Considered clumsy
NERVOUS SYSTEM 0 1 2 3 0 1 2 3
β β β β Convulsions
β β β β Dizziness
β β β β Fainting spells
β β β β Blackouts/amnesia
β β β β Forgetfulness
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 8 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
MENTAL HEALTH 0 1 2 3 0 1 2 3
β β β β Poor memory
β β β β Forgetfulness
β β β β Indecisive
β β β β Confusion
β β β β Mental sluggishness
β β β β Poor concentration
β β β β Frequently keyed up and jittery
β β β β Startled by sudden noises
β β β β Anxiety/Feeling of panic
β β β β Go to pieces easily
β β β β Listless/groggy
β β β β Withdrawn feeling/Feeling βlostβ
β β β β Unable to concentrate/short attention span
β β β β Unable to reason
β β β β Tend to worry needlessly
β β β β Considered a nervous person by others
β β β β Unusual tension
β β β β Frustration
β β β β Emotional numbness
β β β β Often break out in cold sweats
β β β β Profuse sweating
β β β β Depressed
β β β β Often awakened by frightening dreams
β β β β Misunderstood by others
β β β β Irritable
β β β β Feeling of hostility/volatile or aggressive
β β β β Fatigue
β β β β Hyperactive
β β β β Vision changes
β β β β Unable to coordinate muscles
β β β β Have difficulty falling asleep
β β β β Have difficulty staying asleep
β β β β Daytime sleepiness
β β β β Workaholic
β β β β Have had hallucinations
β β β β Feel regular grief
β β β β Feel regular joy
β β β β Often feel relaxed
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 9 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
SLEEP SYMPTOMS 0 1 2 3 0 1 2 3
β β β β Difficulty falling asleep
β β β β Early waking
β β β β Waking between 2:00 and 4:00 am
β β β β Unable to fall back asleep after waking in the night
β β β β Sleep 6 to 8 hours per night
β β β β Wake up unrefreshed
β β β β Daytime sleepiness
β β β β Fatigue
β β β β No dream recall
β β β β Sleepwalker
β β β β Nightmares
β β β β Snoring
β β β β Sleep apnea
MENβS SYMPTOMS (MEN ONLY) 0 1 2 3 0 1 2 3
β β β β Prostate enlargement
β β β β Prostate infection
β β β β Change in libido
β β β β Impotence
β β β β Diminished/poor libido
β β β β Infertility
β β β β Lumps in testicles
β β β β Sore on penis
β β β β Genital pain
β β β β Hernia
β β β β Low sperm count
β β β β Difficulty obtaining erection
β β β β Difficulty maintaining an erection
β β β β Nocturia (urination at night)
β β β β Urgency/Hesitancy/Change in
β β β β Urinary Stream
β β β β Loss of bladder control
β β β β Pain on inside of legs or heels
Β© FUNCTIONAL NUTRITION ALLIANCE LLC page 10 of 10
FREQUENCY SCALE
0 = never 1 = monthly 2 = weekly 3 = daily
WOMENβS SYMPTOMS (WOMEN ONLY) 0 1 2 3 0 1 2 3
β β β β Fibrocystic breasts
β β β β Lumps in breast
β β β β Fibroid Tumors in breasts
β β β β Spotting
β β β β Heavy periods
β β β β Fibroid Tumors in uterus
β β β β Painful periods
β β β β Change in period
β β β β Breast soreness before period
β β β β Endometriosis
β β β β Non-period bleeding
β β β β Breast soreness during period
β β β β Vaginal dryness
β β β β Vaginal discharge
β β β β Partial/total hysterectomy
β β β β Depression during periods
β β β β Hot flashes
β β β β Mood swings
β β β β Concentration/Memory problems
β β β β Ovarian cysts
β β β β Pregnant
β β β β Infertility
β β β β Decreased libido
β β β β Heavy bleeding
β β β β Joint pains
β β β β Headaches
β β β β Weight gain
β β β β Loss of bladder control
β β β β Palpitations
β β β β Thinning skin
β β β β Pain during intercourse
β β β β Food cravings