First Name *Email Address *Phone NumberPlease enter a number between 0 and 4 that best describes your response.Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.1. Feeling that everything is an effort Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely2. Frequent muscle crampsScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.3. Trouble awakening in the morningScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.4. Feeling low in energy or slowed downScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.5. Neck pain or tendernessScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely6. Sleep that is restless or disturbedScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely7. Unexplained diarrhoeaScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely8. Arm pain or tendernessScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely9. Unusual sweating whilst asleep (night sweats)Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely10. Trouble concentratingScores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely11. Abdominal pain or tenderness Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely12. Un-refreshed or prolonged sleep Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.13. Constipation Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.14. Trouble falling asleep Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.15. Shoulder pain or tenderness Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.16. Muscle weakness or weak feeling in the body Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.17. Heavy feeling in the limbs Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.18. Forgetfulness Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.19. Feelings of mental tiredness or fatigue Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.20. Loss of libido or sexual interest Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.21. Symptoms of irritable bowel syndrome Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.22. Muscle soreness or stiffness Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.23. Mental confusion or loss of your train of thought Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.24. Gastric reflux or heartburn Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.25. Face pain or tenderness Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.26. Cravings for certain foods Scores: 0 = not at all, 1 = a little bit; 2 = moderately, 3 = quite a bit; 4 = extremely.Your Summary of ScoresYour score is out of a maximum of 10 and the lower the scores, the better you feel in these symptom categories.General FatigueScore out of 10PainScore out of 10Gut functionScore out of 10SleepScore out of 10VitalityScore out of 10Submit
