Omega Health & Wellness
8761 Perimeter Park Blvd #101
Jacksonville, Florida 32216
(904)374-6498



Health Questionnaire Symptom Update

Date: 11/25/17

First Name:
Middle Initial:
Last Name:



Please click the number that best describes the intensity of your RECENT symptoms.

SYMPTOM

Mild

Severe

Anxiety

1

2

3

4

5

6

7

8

9

10

Arthritis/Joint Pain

1

2

3

4

5

6

7

8

9

10

Bladder Problems

1

2

3

4

5

6

7

8

9

10

Bloating

1

2

3

4

5

6

7

8

9

10

Breast Tenderness

1

2

3

4

5

6

7

8

9

10

Decreased Sex Drive

1

2

3

4

5

6

7

8

9

10

Depression

1

2

3

4

5

6

7

8

9

10

Difficulty Hearing/Ringing in Ears

1

2

3

4

5

6

7

8

9

10

Difficulty Reaching Climax

1

2

3

4

5

6

7

8

9

10

Dry Eyes/Blurred or Double Vision

1

2

3

4

5

6

7

8

9

10

Erectile Dysfunction (males)

1

2

3

4

5

6

7

8

9

10

Fatigue or Weakness

1

2

3

4

5

6

7

8

9

10

Fibrocystic Breasts

1

2

3

4

5

6

7

8

9

10

Fluid Retention

1

2

3

4

5

6

7

8

9

10

Food Cravings and/or Sensitivities

1

2

3

4

5

6

7

8

9

10

Gastro/Intestinal Problems

1

2

3

4

5

6

7

8

9

10

Hair Loss

1

2

3

4

5

6

7

8

9

10

Headaches

1

2

3

4

5

6

7

8

9

10

Heart Palpitations

1

2

3

4

5

6

7

8

9

10

Hot Flashes

1

2

3

4

5

6

7

8

9

10

Irritability

1

2

3

4

5

6

7

8

9

10

Memory/Concentration Issues

1

2

3

4

5

6

7

8

9

10

Mood Swings

1

2

3

4

5

6

7

8

9

10

Nervousness

1

2

3

4

5

6

7

8

9

10

Night Sweats

1

2

3

4

5

6

7

8

9

10

Painful Intercourse

1

2

3

4

5

6

7

8

9

10

PMS (females)

1

2

3

4

5

6

7

8

9

10

Sleep Disturbances

1

2

3

4

5

6

7

8

9

10

Vaginal Dryness (females)

1

2

3

4

5

6

7

8

9

10

Weight Gain

1

2

3

4

5

6

7

8

9

10

Other

1

2

3

4

5

6

7

8

9

10

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