 | |  | |  | |  | |  |
The Food Doc Symptom Survey
Many digestive and non-digestive symptoms occur with digestive or food related illness or
problems. Establishing a link of symptoms or problems to foods or the digestive tract can be
difficult. The first step however involves recognizing symptoms that may be related to food or the
digestive tract. Next, establishing their frequency and severity at a baseline before evaluation and
any dietary intervention is critical. The symptom survey scoring tool below will help you do both.
Complete an initial symptom survey as a baseline and again periodically as needed. It is very
helpful to establish a baseline symptom score before any dietary interventions or elimination diets.
Begin by rating the symptoms below for both frequency and severity using the 0-4 point scale
below. Add up the points in each major body system/category. Make not of high scores in specific
categories as this can be a clue to needing an evaluation of that particular body system.
Next, total up all of your symptom points to reach a grand total. High scores in the digestive-
gastrointestinal category really should be evaluated by a digestive specialist (gastroenterologist).
Most people have some of the symptoms listed below at least occasionally however most healthy
people have a symptom score below 20. Scores often vary seasonally in people with seasonal
allergies. Many non-digestive symptoms occur with digestive or food related illness or problems.
Very high scores (>100) are seen in people with quite severe illness and/or a lot of psychological
problems. Most people with untreated food intolerance will have scores >50, many have scores as
high as 80-120.
With treatment of food allergies, pollen or environmental allergies and treatment of food
intolerances average symptom scores improve over time. The degree of improvement varies but
significant improvement is noted in most people with symptom scores who undergo a complete
digestive and dietary evaluation with specific dietary intervention based on such an evaluation.
SYMPTOM POINT SCALE:
0 = 0 = NEVER suffer from this or only RARELY in past
1 = 1 = OCCASIONALLY suffer from this (less than 2 times per week), NEVER SEVERE
2 = 2 = FREQUENTLY suffer from this (>2 times per week) but symptom NEVER SEVERE
3 = 3 = OCCASIONALLY suffer from this but symptom is SEVERE
4 = 4 = FREQUENTLY suffer from this and symptom is always SEVERE
ENERGY/SLEEP/CONSTITUTIONAL
Fatigue (tired, sluggish)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Daytime Drowsiness
Insomnia (sleep disturbance)
ENERGY/SLEEP/CONSTITUTIONAL TOTAL _____(0-20)
EMOTIONS/MOOD
Depressed Mood
Anxious Mood
Mood Swings
Irritable Mood
EMOTIONS/MOOD TOTAL _____ (0-16)
HEAD/NEUROLOGIC/BRAIN
Migraines
Headaches (not migraines)
Balance Difficulty/Ataxia
Attention Difficulty/ADHD
Numbness-Pain/Neuropathy
Poor Concentration/”Brain Fog”
Seizures
HEAD/NEUROLOGIC/BRAIN TOTAL _____ (0-28)
EYES
Red or Swollen Eyes
Watery/Itchy Eyes
Dark Circles” or “Bags”
EYES TOTAL _____ (0-12)
EARS/NOSE/SINUSES
Sinus Pain/Congestion
Runny Nose
Stuffy Nose
Sneezing
Earaches/Ear Infections
Ringing in Ears
Ear Itching/Discharge
EARS/NOSE/SINUSES TOTAL _____ (0-28)
MOUTH/THROAT
Sore Throat
Lump in Throat
Lips/Tongue/Mouth Swelling
Throat Clearing
Canker Sores
MOUTH/THROAT TOTAL _____ (0-20)
LUNGS/CHEST/CARDIOVASCULAR
Wheezing/Asthma
Chest Congestion/Tightness
Cough
Shortness of Breath
Irregular Heartbeat
High Blood Pressure
LUNGS/CHEST/CARDIOVASCULAR TOTAL _____ (0-24)
DIGESTIVE/GASTROINTESTINAL
Heartburn/Reflux
Swallowing Difficulties
Upper Stomach Pains
Intestinal Pains/Cramps
Constipation
Diarrhea/Loose Stools
Bloating Sensation
Excess Gas
Nausea, Vomiting
DIGESTIVE/GASTROINTESTINAL TOTAL _____ (0-36)
GENITOURINARY
Irregular Menstruation (Women)
Painful Menstruation (Women)
Vaginal or Urethral Discharge
Infertility
Frequent Urination
Painful Urination/Bladder Spasms
Impotence (Men)
Prostate Problems (Men)
GENITOURINARY TOTAL _____(0-24)
WEIGHT/EATING HABITS
Over Weight/Difficult Losing
Food Cravings
Water/Fluid Retention
Binge Eating or Drinking
Purging (all methods)
Underweight
WEIGHT/EATING HABITS TOTAL _____ (0-24)
ENDOCRINE GLANDS
Blood Sugar Problems
Thyroid Problems
Thyroid Pain/Swelling
ENDOCRINE GLANDS TOTAL _____ (0-12)
SKIN/HAIR/NAILS
Acne/Blemishes
Hives
Eczema
Dermatitis Herpetiformis
Hair Loss
Brittle Nails
SKIN/HAIR/NAILS TOTAL _____ (0-24)
MUSCULOSKELETAL
Joint Pains/Aching
Stiff Joints
Muscle Aches/Soreness
Muscle Twitching
MUSCULOSKELETAL TOTAL _____ (0-16)
BLOOD/LYMPHATICS
Excessive Bleeding
Swollen Glands
Easy Bruising
Blood Clots
BLOOD/LYMPHATICS TOTAL _____ (0-12)
ALLERGY/IMMUNE
Hay Fever
Frequent Infections
Yeast Infection
ALLERGY/IMMUNE TOTAL _____(0-12)
COPYRIGHT 2008 THE FOOD DOC LLC. ALL RIGHTS RESERVED www.thefooddoc.com
Many digestive and non-digestive symptoms occur with digestive or food related illness or
problems. Establishing a link of symptoms or problems to foods or the digestive tract can be
difficult. The first step however involves recognizing symptoms that may be related to food or the
digestive tract. Next, establishing their frequency and severity at a baseline before evaluation and
any dietary intervention is critical. The symptom survey scoring tool below will help you do both.
Complete an initial symptom survey as a baseline and again periodically as needed. It is very
helpful to establish a baseline symptom score before any dietary interventions or elimination diets.
Begin by rating the symptoms below for both frequency and severity using the 0-4 point scale
below. Add up the points in each major body system/category. Make not of high scores in specific
categories as this can be a clue to needing an evaluation of that particular body system.
Next, total up all of your symptom points to reach a grand total. High scores in the digestive-
gastrointestinal category really should be evaluated by a digestive specialist (gastroenterologist).
Most people have some of the symptoms listed below at least occasionally however most healthy
people have a symptom score below 20. Scores often vary seasonally in people with seasonal
allergies. Many non-digestive symptoms occur with digestive or food related illness or problems.
Very high scores (>100) are seen in people with quite severe illness and/or a lot of psychological
problems. Most people with untreated food intolerance will have scores >50, many have scores as
high as 80-120.
With treatment of food allergies, pollen or environmental allergies and treatment of food
intolerances average symptom scores improve over time. The degree of improvement varies but
significant improvement is noted in most people with symptom scores who undergo a complete
digestive and dietary evaluation with specific dietary intervention based on such an evaluation.
SYMPTOM POINT SCALE:
0 = 0 = NEVER suffer from this or only RARELY in past
1 = 1 = OCCASIONALLY suffer from this (less than 2 times per week), NEVER SEVERE
2 = 2 = FREQUENTLY suffer from this (>2 times per week) but symptom NEVER SEVERE
3 = 3 = OCCASIONALLY suffer from this but symptom is SEVERE
4 = 4 = FREQUENTLY suffer from this and symptom is always SEVERE
ENERGY/SLEEP/CONSTITUTIONAL
Fatigue (tired, sluggish)
Hyperactive (nervous energy)
Restless (can’t relax/sit still)
Daytime Drowsiness
Insomnia (sleep disturbance)
ENERGY/SLEEP/CONSTITUTIONAL TOTAL _____(0-20)
EMOTIONS/MOOD
Depressed Mood
Anxious Mood
Mood Swings
Irritable Mood
EMOTIONS/MOOD TOTAL _____ (0-16)
HEAD/NEUROLOGIC/BRAIN
Migraines
Headaches (not migraines)
Balance Difficulty/Ataxia
Attention Difficulty/ADHD
Numbness-Pain/Neuropathy
Poor Concentration/”Brain Fog”
Seizures
HEAD/NEUROLOGIC/BRAIN TOTAL _____ (0-28)
EYES
Red or Swollen Eyes
Watery/Itchy Eyes
Dark Circles” or “Bags”
EYES TOTAL _____ (0-12)
EARS/NOSE/SINUSES
Sinus Pain/Congestion
Runny Nose
Stuffy Nose
Sneezing
Earaches/Ear Infections
Ringing in Ears
Ear Itching/Discharge
EARS/NOSE/SINUSES TOTAL _____ (0-28)
MOUTH/THROAT
Sore Throat
Lump in Throat
Lips/Tongue/Mouth Swelling
Throat Clearing
Canker Sores
MOUTH/THROAT TOTAL _____ (0-20)
LUNGS/CHEST/CARDIOVASCULAR
Wheezing/Asthma
Chest Congestion/Tightness
Cough
Shortness of Breath
Irregular Heartbeat
High Blood Pressure
LUNGS/CHEST/CARDIOVASCULAR TOTAL _____ (0-24)
DIGESTIVE/GASTROINTESTINAL
Heartburn/Reflux
Swallowing Difficulties
Upper Stomach Pains
Intestinal Pains/Cramps
Constipation
Diarrhea/Loose Stools
Bloating Sensation
Excess Gas
Nausea, Vomiting
DIGESTIVE/GASTROINTESTINAL TOTAL _____ (0-36)
GENITOURINARY
Irregular Menstruation (Women)
Painful Menstruation (Women)
Vaginal or Urethral Discharge
Infertility
Frequent Urination
Painful Urination/Bladder Spasms
Impotence (Men)
Prostate Problems (Men)
GENITOURINARY TOTAL _____(0-24)
WEIGHT/EATING HABITS
Over Weight/Difficult Losing
Food Cravings
Water/Fluid Retention
Binge Eating or Drinking
Purging (all methods)
Underweight
WEIGHT/EATING HABITS TOTAL _____ (0-24)
ENDOCRINE GLANDS
Blood Sugar Problems
Thyroid Problems
Thyroid Pain/Swelling
ENDOCRINE GLANDS TOTAL _____ (0-12)
SKIN/HAIR/NAILS
Acne/Blemishes
Hives
Eczema
Dermatitis Herpetiformis
Hair Loss
Brittle Nails
SKIN/HAIR/NAILS TOTAL _____ (0-24)
MUSCULOSKELETAL
Joint Pains/Aching
Stiff Joints
Muscle Aches/Soreness
Muscle Twitching
MUSCULOSKELETAL TOTAL _____ (0-16)
BLOOD/LYMPHATICS
Excessive Bleeding
Swollen Glands
Easy Bruising
Blood Clots
BLOOD/LYMPHATICS TOTAL _____ (0-12)
ALLERGY/IMMUNE
Hay Fever
Frequent Infections
Yeast Infection
ALLERGY/IMMUNE TOTAL _____(0-12)
COPYRIGHT 2008 THE FOOD DOC LLC. ALL RIGHTS RESERVED www.thefooddoc.com
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
| |
 |
|
| |
|
| |
|
| |
|
| |
|
| |
|
| |
|