Symptom Follow-Up Symptom Follow Up Date* MM slash DD slash YYYY Name* First Last Practitioner* ConstitutionalInstuctions: Score every symptom based on your experience OVER THE PAST WEEK. Using the SCALE OF SYMPTOM POINTS listed below, type in the appropriate score to the left of EVERY symptom listed. The amounts will be totaled at the bottom. Also note the number of missed work days you have had in the last week due to illness. Scale of Symptom points: - If you did not suffer from the symptom ever or almost never, leave it blank. 1 = OCCASIONALLY (less than 2 times per week) and symptom was MILD 2 = FREQUENTLY (2 or more times per week) and symptom was MILD 3 = OCCASSIONALLY (less than 2 times per week) and symptom was SEVERE 4 = FREQUENTLY (2 or more times per week) and symptom was SEVERESymptom 1*Symptom 2*Symptom 3*Symptom Set 1 Total (0-28)*
