| Section C: Other Symptoms | ||
| Instructions: For each symptom that is present, enter the appropriate number in the Point Score Column. If a symptom is occasional or mild…………………..……score 3 points. If a symptom is frequent and/or moderately severe….....score 6 points. If a symptom is severe and/or persistent………………...score 9 points. Total the score for this section and record it in the box at the end of this section. | ||
| | | Point Score |
| 1. | Drowsiness | 3 / 6 / 9 |
| 2. | Irritability or jitteriness | 3 / 6 / 9 |
| 3. | Uncoordinated | 3 / 6 / 9 |
| 4. | Inability to concentrate | 3 / 6 / 9 |
| 5. | Frequent mood swings | 3 / 6 / 9 |
| 6. | Headache | 3 / 6 / 9 |
| 7. | | 3 / 6 / 9 |
| 8. | Pressure above ears, feeling of head swelling/tingling | 3 / 6 / 9 |
| 9. | Tendency to bruise easily | 3 / 6 / 9 |
| 10. | Chronic rashes or itching | 3 / 6 / 9 |
| 11. | Psoriasis or recurrent hives | 3 / 6 / 9 |
| 12. | Indigestion or heartburn | 3 / 6 / 9 |
| 13. | Food sensitivity or intolerance | 3 / 6 / 9 |
| 14. | Mucus in stools | 3 / 6 / 9 |
| 15. | Hemorrhoids or rectal itching | 3 / 6 / 9 |
| 16. | Dry Mouth or throat | 3 / 6 / 9 |
| 17. | Rash or blisters in mouth | 3 / 6 / 9 |
| 18. | Bad breath | 3 / 6 / 9 |
| 19. | Foot, hair or body odor not relieved by washing | 3 / 6 / 9 |
| 20. | Nasal congestion, discharge or post nasal drip | 3 / 6 / 9 |
| 21. | Nasal itching | 3 / 6 / 9 |
| 22. | Sore or dry throat | 3 / 6 / 9 |
| 23. | Laryngitis, loss of voice | 3 / 6 / 9 |
| 24. | Cough or recurrent bronchitis | 3 / 6 / 9 |
| 25. | Pain or tightness in chest | 3 / 6 / 9 |
| 26. | Wheezing or shortness of breath | 3 / 6 / 9 |
| 27. | Urgency frequency, urgency or incontinence | 3 / 6 / 9 |
| 28. | Burning on urination | 3 / 6 / 9 |
| 29. | Spots in front of eyes or erratic vision | 3 / 6 / 9 |
| 30. | Burning or tearing of eyes | 3 / 6 / 9 |
| 31. | Recurrent infections or fluid in ears | 3 / 6 / 9 |
| 32. | Ear pain or deafness | 3 / 6 / 9 |
| | Total Score – Section C | |