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)

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