Location

3446 Mt. Diablo Blvd.
Lafayette, CA 94549

Store Hours

Mon – Fri 10:00 – 05:30
Sat. – 09:00 – 02:00

INSTRUCTIONS: Score every symptom based on your experience OVER THE PAST WEEK. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score to the left of EVERY symptom listed. 

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 = OCCASIONALLY (less than 2 times per week) and symptom was SEVERE 4 = FREQUENTLY (2 or more times per week) and symptom was SEVERE

  • MM slash DD slash YYYY
  • CONSTITUTIONAL

  • EMOTIONAL/MENTAL

  • HEAD/EARS

  • SKIN

  • NASAL/SINUS

  • MOUTH/THROAT

  • LUNGS

  • EYES

  • GENITOURINARY

  • MUSCULOSKELETAL

  • CARDIOVASCULAR

  • DIGESTIVE

  • WEIGHT MANAGEMENT

  • Please enter a number from 1 to 10.
  • Please enter a number from 0 to 21.
  • This field is for validation purposes and should be left unchanged.