Symptom Check List – HTMABy marykatehoogland / November 6, 2025 NameEmail AddressInstructions: Please rate each symptom based on how frequently or severely you experience it using the following scale: 0 = Never/Not at all 1 = Rarely/Mild 2 = Occasionally/Moderate 3 = Frequently/Severe 4 = Constantly/Very SevereENERGY & FATIGUE ISSUESEnergy and FatiguePlease tick any that applyChronic fatigue or low energyDifficulty waking up in the morningEnergy crashes during the dayNeed for afternoon napsWeakness or heaviness in limbsAny other commentsMENTAL & COGNITIVE PROBLEMSMental and CognitionTick the ones that applyBrain fog or difficulty concentratingPoor memory or forgetfulnessMental confusionDifficulty making decisionsSlowed thinkingAny other commentsMOOD & EMOTIONAL ISSUESMood and emotionsTick the ones that applyDepression or low moodAnxiety or nervousnessIrritability or mood swingsFeeling overwhelmed easilyPanic attacksApathy or lack of motivationAny other commentsSLEEP DISTURBANCESSleepTick the ones that applyDifficulty falling asleepWaking during the nightUnrefreshing sleepNightmares or vivid dreamsRestless legs at nightAny other commentsDIGESTIVE ISSUESDigestionTick the ones that applyBloating or gasConstipationDiarrheaHeartburn or acid refluxNauseaPoor appetiteFood sensitivitiesAbdominal pain or crampingAny other commentsBLOOD SUGAR DISREGULATIONBlood SugarTick the ones that applyCravings for sweets or carbohydratesShakiness or lightheadedness between mealsIrritability when hungryNeed to eat frequentlyAny other commentsTHYROID/METABOLISM PROBLEMSThyroid /MetabolismTick the ones that applyCold hands or feetSensitivity to cold temperaturesWeight gain or difficulty losing weightUnexplained weight lossDry skinHair loss or thinningBrittle nailsSlow wound healingAny other commentsCARDIOVASCULAR ISSUESCardiovascularTick the ones that applyHeart palpitationsRapid heartbeatChest tightnessHigh blood pressureLow blood pressureDizziness upon standingAny other commentsMUSCULAR & SKELETALMuscular and SkeletalTick the ones that applyMuscle cramps or spasmsMuscle weaknessJoint pain or stiffnessBone painMuscle twitchingBack painNEUROLOGICAL ISSUESNeurologicalTick the ones that applyHeadachesMigrainesNumbness or tingling (specify location)Tremors or shakingPoor coordinationSensitivity to light or soundAny other commentsHORMONAL IMBALANCEHormonalTick the ones that applyPMS symptomsIrregular menstrual cyclesHeavy or painful periodsHot flashesLow libidoMenopause symptomsAny other commentsSKIN, HAIR & NAILS PROBLEMSSkin Hair and NailsTick the ones that applyAcne or skin breakoutsEczema or rashesExcessive drynessPremature grayingWhite spots on nailsRidges on nailsBrittle nailsSlow wound healingAny other commentsIMMUNE & INFLAMMATIONImmune & InflammationTick the ones that applyFrequent colds or infectionsSlow recovery from illnessAllergiesChemical sensitivitiesInflammation or swellingAutoimmune symptomsAny other commentsSTRESS & ADRENAL FATIGUEStress and Adrenal FatigueTick the ones that applyFeeling "wired but tired"Difficulty handling stressBurnout sensationNeed for stimulants (coffee, etc.)Salt cravingsOTHER SYMPTOMSTick the ones that applyDental problems (cavities, sensitivity)Ringing in ears (tinnitus)Vision problemsFrequent urinationExcessive thirstWater retentionANY ADDITIONAL COMMENTSSubmit Share this: Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook Like this:Like Loading... Related
