3100 Cross Creek Parkway Suite 220, Auburn Hills, MI 48326 |
(248) 325-8549
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QUESTIONNAIRE
QUESTIONNAIRE
Tahki Institute Patient Intake Form
Health Symptoms Questionnaire
GI Health Appraisal Questionnaire
Male Hormone Questionnaire
Female Hormone Questionnaire
BLOG
Contact Us
ABOUT US
About US
Our Mission & Vision
FAQ
FOUR PILLARS
FEATURED SERVICES
HORMONE REPLACEMENT THERAPY
WEIGHT LOSS
GUT HEALTH & MICROBIOME RESTORATION
TED HAIR RESTORATION
COUNSELING & COACHING
QUESTIONNAIRE
Tahki Institute Patient Intake Form
Health Symptoms Questionnaire
GI Health Appraisal Questionnaire
Male Hormone Questionnaire
Female Hormone Questionnaire
BLOG
Contact Us
Health Symptoms Questionnaire
Health Symptoms Questionnaire
Name
Date
Rate each of the following symptoms based on the last week using the point scale below:
0 - Never or rarely have the symptom
3 - Frequently have it, effect is not severe
1 - Occasionally have it, effect is not severe
4 - Frequently have it, effect is severe
2 - Occasionally have it, effect is severe
Digestive tract
Nausea, vomiting
0
1
2
3
4
Diarrhea
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated feeling
0
1
2
3
4
Heartburn
0
1
2
3
4
Intestinal, stomach pain
0
1
2
3
4
Digestive tract total:
0
Joints / muscles
Pain or aches in joints
0
1
2
3
4
Arthritis, joint swelling
0
1
2
3
4
Stiff or limitation of movement
0
1
2
3
4
Pain or aches in muscles
0
1
2
3
4
Feeling of weakness or tired
0
1
2
3
4
Joints / muscles total:
0
Emotional
Mood swings
0
1
2
3
4
Anxiety, fear, nervousness
0
1
2
3
4
Anger, irritability, aggression
0
1
2
3
4
Depression
0
1
2
3
4
Emotional total:
0
Weight / food
Binge eating, drinking
0
1
2
3
4
Craving certain foods
0
1
2
3
4
Excessive weight
0
1
2
3
4
Compulsive eating, food addictions
0
1
2
3
4
Water retention
0
1
2
3
4
Underweight
0
1
2
3
4
Weight / food total:
0
Energy / sleep
Fatigue, sluggishness
0
1
2
3
4
Apathy, lethargy
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Restlessness, achiness
0
1
2
3
4
Sleep disturbances
0
1
2
3
4
Energy / sleep total:
0
Skin
Acne
0
1
2
3
4
Hives, rashes, dry skin, redness
0
1
2
3
4
Hair loss
0
1
2
3
4
Flushing, hot flashes
0
1
2
3
4
Excessive sweating
0
1
2
3
4
Skin total:
0
Heart
Irregular or skipped heartbeat
0
1
2
3
4
Rapid or pounding heartbeat
0
1
2
3
4
Chest pain
0
1
2
3
4
Heart total:
0
Other
Frequent illness
0
1
2
3
4
Frequent or urgent urination
0
1
2
3
4
Genital itch or discharge
0
1
2
3
4
Other total:
0
Respiratory
Chest congestion
0
1
2
3
4
Asthma, bronchitis
0
1
2
3
4
Shortness of breath
0
1
2
3
4
Difficulty breathing
0
1
2
3
4
Respiratory total:
0
Eyes
Watery or itchy eyes
0
1
2
3
4
Swollen, red, or sticky eyelids
0
1
2
3
4
Bags or dark circles under eyes
0
1
2
3
4
Blurred or restricted vision
0
1
2
3
4
Eyes total:
0
Nose
Stuffy nose
0
1
2
3
4
Sinus problems or dripping nose
0
1
2
3
4
Hay fever
0
1
2
3
4
Sneezing attacks
0
1
2
3
4
Excessive mucus
0
1
2
3
4
Nose total:
0
Mouth / throat
Frequent, consistent coughing
0
1
2
3
4
Gagging, need to clear throat
0
1
2
3
4
Sore throat, hoarse, loss of voice
0
1
2
3
4
Swollen or discolored tongue, gums, or lips
0
1
2
3
4
Canker sores, other mouth sores
0
1
2
3
4
Mouth / throat total:
0
Ears
Itchy ears
0
1
2
3
4
Earaches, ear infections
0
1
2
3
4
Draining from ear, waxy buildup
0
1
2
3
4
Ringing in ears, hearing loss
0
1
2
3
4
Ears total:
0
Head
Headaches
0
1
2
3
4
Faintness or lightheadedness
0
1
2
3
4
Dizziness
0
1
2
3
4
Head total:
0
Cognitive
Poor memory recall
0
1
2
3
4
Confusion, poor comprehension
0
1
2
3
4
Poor concentration
0
1
2
3
4
Poor physical coordination
0
1
2
3
4
Difficulty making decisions
0
1
2
3
4
Stuttering, stammering
0
1
2
3
4
Slurred speech
0
1
2
3
4
Learning disabilities
0
1
2
3
4
Cognitive total:
0
Grand Total:
0
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