FLT Health Profile Name* Date* MM slash DD slash YYYY Week* Rate each of the following based upon your typical health profile for: past 30 days past 48 hours HeadHeadaches*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeFaintness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDizziness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeInsomnia*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* EyesWatery or itchy eyes*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSwollen, Reddened or sticky eyelids*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeBags or dark circles under eyes*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeBlurred or tunnel vision (does not include near- or far-sightedness)*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* EarsItchy ears*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeEaraches, ear infections*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDrainage from ear*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeRinging in ears, hearing loss*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* NoseStuffy nose*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSinus problems*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeHay fever*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSneezing attacks*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeExcessive mucus formation*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* Mouth/ThroatChronic coughing*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeGagging, frequent need to clear throat*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSore throat, hoarseness, loss of voice*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSwollen or discolored tongue, gums or lips*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeCanker sores*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* SkinAcne*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeHives, rashes, dry skin*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeHair loss*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeFlushing, hot flashes*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeExcessive sweating*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* HeartIrregular or skipped heartbeat*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeRapid or pounding heartbeat*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeChest pain*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* LungsChest congestion*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeAsthma, bronchitis*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDifficulty breathing*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeShortness of breath*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* Digestive TractNausea, vomiting*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDiarrhea*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeConstipation*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeBloated feeling*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeBelching, passing gas*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeHeartburn*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeIntestinal/stomach pain*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* Joints/MusclePain or aches in joints*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeArthritis*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeStiffness or limitation of movement*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severePain or aches in muscles*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeFeeling of weakness or tiredness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* WeightBinge eating/drinking*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeCraving certain foods*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeExcessive weight*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeCompulsive eating*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeWater retention*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeUnderweight*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* Energy/ActivityFatigue, sluggishness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeApathy, lethargy*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeHyperactivity*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeRestlessness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* MindPoor memory*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeConfusion, poor comprehension*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severePoor concentration*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severePoor physical coordination*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDifficulty in making decisions*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeStuttering or stammering*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeSlurred speech*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeLearning disabilities*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* EmotionsMood swings*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeAnxiety, fear, nervousness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeAnger, irritability, aggressiveness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeDepression*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* OtherFrequent illness*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeFrequent or urgent urination*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeGenital itch or discharge*0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequently have it, effect is severeTotal* Grand TotalTotal*
