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My Symptom Questionnaire

Rate each of the following symptoms based on your typical health profile for the past 2 weeks. Please look carefully at the scale below before you begin. Note that some answers reflect "severe" and "not severe." 

This questionnaire is not intended to replace visits with your physician. The total score is not meant to diagnose any condition. It will be used to track how our therapeutic interventions improve your symptoms over time.


All responses are HIPAA-protected and kept private and confidential.

Point Scale:
0 = Never        

1 = Rarely. Effect NOT severe   

2 = Occasionally. Effect NOT severe

3 = Occasionally. Effect severe   

4 = Frequently. Effect NOT severe

5 = Frequently. Effect severe     

Important: By clicking Submit, you are consenting to have the information electronically delivered to Living Renewed's HIPAA-compliant portal. You also consent to be contacted by a representative of Living Renewed to briefly review your responses and your interest in participating in our program. 

Submission is governed by our Privacy Policy

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