Level 1 Beginning Evaluation
Primary Symptom/ Diagnosis
Anxiety/Depression
Autoimmune Condition
Chronic Fatigue Syndrome/ ME
Food Sensitivities / Gastrointestinal Symptoms
Insomnia
Long Haul Covid
Lyme
Migraines
Mold / CIRS
Neurological Disorders
POTS
Vertigo
Something Else
Primary Symptom/ Diagnosis
Anxiety/Depression
Autoimmune Condition
Chronic Fatigue Syndrome/ ME
Food Sensitivities / Gastrointestinal Symptoms
Insomnia
Long Haul Covid
Lyme
Migraines
Additional Symptoms
Anxiety/Depression
Autoimmune Condition
Chronic Fatigue Syndrome/ ME
Food Sensitivities / Gastrointestinal Symptoms
Insomnia
Long Haul Covid
Lyme
Migraines
Mold / CIRS
Neurological Disorders
POTS
Vertigo
Something Else
Physical Function: What is your overall functional capacity on a scale of 1-10?
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10
"I am bedbound and/or housebound"
"I am physically able to engage in all of the daily activities I desire"
Emotional/Mental Function: How much of your day are you experiencing a stress response on a scale of 1-10?
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10
"I rarely feel stressed"
"I'm always stressed"
If you have had fatigue: How would you rate the fatigue you experience currently?
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10
"I only experience fatigue occasionally and can function well overall"
"Fatigue is terrible - I barely have energy at all"
If you have had pain: What would you rate the pain you experience currently?
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10
"I experience little to no pain"
"The pain I experience is incapacitating"
On a scale of 1-10, which of these statements do you feel most resonates with your current quality of life?
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10
"I find it challenging to maintain a sense of well-being and purpose in life"
"I feel a strong sense of well-being and purpose in life"
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