Symptom Quiz | Rose Wellness

Runny or drippy nose atleast 1-2 times per month

None
Mild
Moderate
Severe

Catch colds with the change of seasons

None
Mild
Moderate
Severe

Mucus producing cough prolonged for 1 or more months

None
Mild
Moderate
Severe

How often do you get colds and/or other viral/respiratory infections (None - 1 or less/year, Mild = 3 or less/year, Moderate 5 or less/year, Severe 6 or more/year)

None
Mild
Moderate
Severe

How often do you get other infections (None - 1 or less/year, Mild = 3 or less/year, Moderate 5 or less/year, Severe 6 or more/year)

None
Mild
Moderate
Severe

Recurrent or chronic acne (adult)

None
Mild
Moderate
Severe

Recurrent or chronic itchy skin/rashes (dermatitis)

None
Mild
Moderate
Severe

Recurrent or chronic Cysts, boils, rashes

None
Mild
Moderate
Severe

History of epstein-bar, mono, herpes, shingles, chronic fatigue syndrome, hepatitis, or other chronic viral conditions

None
Mild
Moderate
Severe

Recurrent or chronic bloating, belching, gas

None
Mild
Moderate
Severe

Recurrent or chronic heartburn or acid reflux

None
Mild
Moderate
Severe

Sense of excess fullness after meals

None
Mild
Moderate
Severe

Feel better if you don’t eat

None
Mild
Moderate
Severe

Stomach pains or cramps relieved after a bowel movement

None
Mild
Moderate
Severe

Diarrhea, chronic or recurrent

None
Mild
Moderate
Severe

Constipation, chronic or recurrent

None
Mild
Moderate
Severe

Undigested food in stools

None
Mild
Moderate
Severe

Food allergies or sensitivities

None
Mild
Moderate
Severe

Recurrent or chronic asthma, sinus infections, stuffy nose

None
Mild
Moderate
Severe

Recurrent or chronic sinus congestion, "stuffy head"

None
Mild
Moderate
Severe

Shortness of breath with moderate exertion

None
Mild
Moderate
Severe

Ankles swell, especially at the end of the day

None
Mild
Moderate
Severe

Recurrent or chronic palpitations or racing heart

None
Mild
Moderate
Severe

Abnormal weight gain

None
Mild
Moderate
Severe

Excessive hunger or thirst

None
Mild
Moderate
Severe

High cholesterol

None
Mild
Moderate
Severe

High blood sugar

None
Mild
Moderate
Severe

High blood pressure

None
Mild
Moderate
Severe

Frequent urination

None
Mild
Moderate
Severe

Low energy, fatigue, lethargy

None
Mild
Moderate
Severe

Mentally sluggish, trouble concentrating

None
Mild
Moderate
Severe

Feel cold easily, especially hands and feet

None
Mild
Moderate
Severe

Gain weight easily or struggle losing weight even with good diet/exercise

None
Mild
Moderate
Severe

Recurrent or chronic constipation

None
Mild
Moderate
Severe

Excessive hair loss

None
Mild
Moderate
Severe

Thinning or loss of outside third of eyebrows

None
Mild
Moderate
Severe

Depression, lack of motivation

None
Mild
Moderate
Severe

Dry skin

None
Mild
Moderate
Severe

Menstrual problems

None
Mild
Moderate
Severe

Recurrent or chronic headaches

None
Mild
Moderate
Severe

Crave salt or sugar

None
Mild
Moderate
Severe

Trouble getting up in the morning

None
Mild
Moderate
Severe

Continued fatigue, not relieved by sleep or rest

None
Mild
Moderate
Severe

Decreased ability to handle stress or get stressed easily

None
Mild
Moderate
Severe

Recurrent or chronic low mood

None
Mild
Moderate
Severe

Brain fog or poor mental clarity

None
Mild
Moderate
Severe

Higher energy after dinner or before bed

None
Mild
Moderate
Severe

Frequently feel stressed, overwhelmed, and exhausted

None
Mild
Moderate
Severe

Weak immune system (susceptible to cold/flu)

None
Mild
Moderate
Severe

Excessive need for sleep

None
Mild
Moderate
Severe

Depend on coffee to keep yourself going or to get started

None
Mild
Moderate
Severe

Get lightheaded or irritable if meals are missed

None
Mild
Moderate
Severe

Feel shaky, jittery, tremors

None
Mild
Moderate
Severe

Agitated, easily upset, nervous

None
Mild
Moderate
Severe

Depression, lack of motivation, apathy

None
Mild
Moderate
Severe

Worry, anxiety

None
Mild
Moderate
Severe

Obsessive thoughts or behaviors

None
Mild
Moderate
Severe

Mood swings, Irritability, anger

None
Mild
Moderate
Severe

Panic attacks, phobias

None
Mild
Moderate
Severe

Insomnia, disturbed sleep

None
Mild
Moderate
Severe

Lack of focus, concentration

None
Mild
Moderate
Severe

Hard to relax, loosen up, get to sleep, be still

None
Mild
Moderate
Severe

Eat to relieve stress

None
Mild
Moderate
Severe

Premenstrual or menopausal mood swings or food cravings

None
Mild
Moderate
Severe

Irregular periods

None
Mild
Moderate
Severe

Menstrual headaches or migraines

None
Mild
Moderate
Severe

Excessive cramping, bleeding or breast tenderness before or during menses

None
Mild
Moderate
Severe

Postmenopausal discomfort (hot flashes/night sweats, weight gain, insomnia, mental dullness)

None
Mild
Moderate
Severe

PCOS (Polycystic Ovarian Syndrome)

None
Mild
Moderate
Severe

Uterine Fibroids or Endometriosis

None
Mild
Moderate
Severe

Fibrocystic breasts

None
Mild
Moderate
Severe

Recurrent or chronic trouble sleeping

None
Mild
Moderate
Severe

Muscle weakness or reduced muscle mass

None
Mild
Moderate
Severe

Reduced sense of well being

None
Mild
Moderate
Severe

Reduced libido

None
Mild
Moderate
Severe

Moodiness, lack of motivation

None
Mild
Moderate
Severe

Apathy or reduced purpose

None
Mild
Moderate
Severe

Increased blood sugar levels

None
Mild
Moderate
Severe

Increased abdominal fat or carb cravings

None
Mild
Moderate
Severe

Joint aches and pains

None
Mild
Moderate
Severe

Bone loss

None
Mild
Moderate
Severe

First Name *

Last Name *

Email *

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What state do you reside in? *

Primary Health Concern *

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