How to Use / Point Scale

Rate each of the following symptoms based upon your health for the past thirty (30) days on a scale of 0 to 4.

• 0 = Never, or almost never have the symptom
• 1 = Occasionally have it, effect is not severe
• 2 = Occasionally have, effect is severe
• 3 = Frequently have it, effect is not severe
• 4 = Frequently have it, effect is severe

This interactive form will return a score for each section and a grand total upon completion. Be sure to look at your score before clearing the page as results are not cached.

Results Key to Questionnaire

• Optimal Health – Less than 10
• Mild Toxicity – 10 to 50
• Moderate Toxicity: 50-100
• Severe Toxicity: over 100

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