Medical Symptom Questionnaire

Is Green Mountain’s Healing with Food Program Right for You?

Rate each of the following symptoms based upon your typical health profile for the past 30 days.  Add up scores for each group, then add all for Grand Total.

If you score over 30, Green Mountain’s Healing with Food may be able to help.

Point Scale

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

Total

Eyes

Total

Ears

Total

Nose

Total

Mouth/Throat

Total

Skin

Total

Heart

Total

Lungs

Total

Digestive Tract

Total

Joints/Muscle

Total

Weight

Total

Energy/Activity

Total

Mind

Total

Emotions

Total

Other

Total

Grand Total


Grand Total Scores

  • Less than 10 is optimal.
  • 10 to 50 = Mild
  • 50 to 100 = Moderate
  • Over 100 = Severe

The higher your score, the more likely our Healing with Food program can help you feel better and end struggles with eating and healthy living.

Questionnaire courtesy of the Institute for Functional Medicine


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