SAFM: Symptom Questionnaire. Take a free online course without registration.

76

Headache

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

75

Weakness, tendency to faint

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

74

Dizziness

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

73

Insomnia

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

72

Stuffy nose

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

71

Sinus issues

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

70

Hay fever

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

69

Sneezing fits

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

68

Excessive mucus production

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

67

Chronic cough

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

66

Vomiting or frequent need to clear the throat

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

65

Sore throat, hoarseness, or loss of voice

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

64

Swollen or discolored tongue, gums, or lips

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

63

Chronic pain in the teeth or gums or jaw pain. What exactly?

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

62

Stomatitis

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

61

Acne

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

60

Urticaria or other allergic rashes

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

59

Rash or constantly dry skin

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

58

Hair loss

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

57

Redness or flushes

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

56

I often feel cold.

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

55

Excessive sweating

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

54

Body parts often go numb. Which ones exactly?

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

53

Irregular or missed heartbeat

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

52

Rapid or strong heartbeat

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

51

Chest pain

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

50

Congestion in the chest

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

49

Asthma, bronchitis

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

48

Shortness of breath

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

47

Shortness of breath

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

46

Nausea or vomiting

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

45

Diarrhea

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

44

Constipation

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

43

Feeling of bloating

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

42

Belch

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

41

Gas formation, flatulence

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

40

Heartburn

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

39

Pain in the intestines or stomach. Which one exactly?

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

38

Another pain in the gastrointestinal tract? Where?

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

37

Pain or ache in the joints

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

36

Arthritis

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

35

Stiffness or restriction of movement

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

34

Pain or soreness in the muscles

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

33

Tremor or restless leg

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

32

Feeling of weakness or fatigue

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

31

Overeating / drunkenness

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

30

Craving for certain products

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

29

Excess weight

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

28

Binge eating

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

27

Water retention

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

26

Underweight

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

25

Fatigue, lethargy

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

24

Apathy, lethargy

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

23

Hyperactivity

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

22

Anxiety

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

21

Poor memory

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

20

Confusion, misunderstanding

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

19

Poor concentration or attention

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

18

Poor physical coordination

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

17

Difficulties in decision-making

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

16

Stuttering or hesitations

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

15

Learning disability

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

14

Mood swings

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

13

Anxiety, fear, nervousness

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

12

Anger, irritability, aggressiveness

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

11

Depression

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

10

Other mood issues?

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

9

Common diseases

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

8

Frequent or urgent urination

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

7

Inability to urinate or low urine flow

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

6

Low libido or other sexual dysfunction.

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

5

Genital itching or discharge

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

4

Women: breast fibroma

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

3

Women: painful or sensitive breasts

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

2

Women: uterine fibroids

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

1

Other

Never had any symptoms. Sometimes, the effect is light. Sometimes, the effect is serious. Often or constantly, the effect is mild. Often or constantly, the effect is serious.

Name		Place of Residence
Email Address		Contact (Phone/Telegram/WhatsApp)
Age		Height
Date of Birth		Place of Birth
Current Weight		Weight Six Months Ago
Weight One Year Ago		Desired Weight (if you want to change)
Marital Status		Children
Occupation		Work Hours per Week

Sleep
Do you sleep well?		What time do you go to bed?
How many hours do you sleep?		Do you wake at night? (what time)
Reason for awakenings

Are your periods regular?		How many days?
How often?		Painful/symptomatic?

Frequently eaten foods in childhood
Breakfast	Lunch	Dinner	Snacks	Fluids

What you usually eat now
Breakfast	Lunch	Dinner	Snacks	Fluids

Mother’s Health History	Father’s Health History

Do you have amalgam fillings (silver/mercury)? Other major work?
Energy level (1–10). What do you attribute it to?

JOINTS & MUSCLES
Joint pain or aches
Arthritis
Stiffness/limited range of motion
Muscle pain or aches
Tremor or “restless legs”
Feeling of weakness or fatigue

WEIGHT
Overeating / binge drinking
Cravings for specific foods
Excess body weight
Compulsive overeating
Water retention
Underweight

SAFM: Symptom Questionnaire

SAFM: Confidential Health History

Symptom Questionnaire