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Inflammation Questionnaire: General Signs & Symptoms
Ludwig Family Chiropractic - (620) 257-2040 - 400 W. Main St., Lyons, KS, 67554
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First and Last Name
*
Your answer
Head
*
0
1
2
3
4
Headaches
Dizziness
Insomnia
Faintness
0
1
2
3
4
Headaches
Dizziness
Insomnia
Faintness
Ears
*
0
1
2
3
4
Itchy Ears
Ringing in ears/ loss of hearing
Earaches/ ear infections
Drainage from ear
0
1
2
3
4
Itchy Ears
Ringing in ears/ loss of hearing
Earaches/ ear infections
Drainage from ear
Eyes
*
0
1
2
3
4
Bags or dark circles under eyes
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Blurred or tunnel vision (excluding near or far sightedness)
0
1
2
3
4
Bags or dark circles under eyes
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Blurred or tunnel vision (excluding near or far sightedness)
Nose
*
0
1
2
3
4
Stuffy nose
Sinus congestion, sinus infection
Constant sneezing
Hay fever/ allergies
Excess mucus formation
0
1
2
3
4
Stuffy nose
Sinus congestion, sinus infection
Constant sneezing
Hay fever/ allergies
Excess mucus formation
Mouth
*
0
1
2
3
4
Chronic coughing
Sore throat, hoarseness, loss of voice
Gagging, frequent need to clear throat
Swollen tongue, gums, or lips
Swollen lymph nodes
Canker cores, mouth ulcers
0
1
2
3
4
Chronic coughing
Sore throat, hoarseness, loss of voice
Gagging, frequent need to clear throat
Swollen tongue, gums, or lips
Swollen lymph nodes
Canker cores, mouth ulcers
Heart
*
0
1
2
3
4
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
0
1
2
3
4
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Lungs
*
0
1
2
3
4
Asthma, bronchitis
Chest congestion
Shortness of breath
Difficulty breathing
0
1
2
3
4
Asthma, bronchitis
Chest congestion
Shortness of breath
Difficulty breathing
Skin
*
0
1
2
3
4
Acne or brown "age/liver spots"
Hives, rashes, cysts, boils
Eczema or psoriasis
Itchy skin/ dermatitis
Hair loss, hair thinning
Body odor
Excessive sweating
0
1
2
3
4
Acne or brown "age/liver spots"
Hives, rashes, cysts, boils
Eczema or psoriasis
Itchy skin/ dermatitis
Hair loss, hair thinning
Body odor
Excessive sweating
Joints/Muscles
*
0
1
2
3
4
Pain or aches in joints or lower back
Stiffness or limitation of movement
Arthritis
Pain or aches in muscles
0
1
2
3
4
Pain or aches in joints or lower back
Stiffness or limitation of movement
Arthritis
Pain or aches in muscles
Mental/Emotional
*
0
1
2
3
4
Poor memory
Difficulty concentrating
Mood swings
Depression
Anxiety, fear, or nervousness
Anger, irritability, or aggressiveness
Insomnia
0
1
2
3
4
Poor memory
Difficulty concentrating
Mood swings
Depression
Anxiety, fear, or nervousness
Anger, irritability, or aggressiveness
Insomnia
Energy Level
*
0
1
2
3
4
Fatigue/ low energy
Restlessness
Hyperactivity
Feeling of weakness
0
1
2
3
4
Fatigue/ low energy
Restlessness
Hyperactivity
Feeling of weakness
Weight
*
0
1
2
3
4
Underweight
Overweight
Difficulty losing weight
Crave certain foods
0
1
2
3
4
Underweight
Overweight
Difficulty losing weight
Crave certain foods
Digestive Tract
*
0
1
2
3
4
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/ stomach pain
0
1
2
3
4
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/ stomach pain
Other
*
0
1
2
3
4
PMS
Frequent colds, flus
Chemical or environmental sensitivities
Food allergies/ sensitivities (if testing performed)
0
1
2
3
4
PMS
Frequent colds, flus
Chemical or environmental sensitivities
Food allergies/ sensitivities (if testing performed)
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