Rate symptoms for the last 90 days. Scores update automatically.
⚠️ Complete Other Forms First
This form is designed for complex cases and works alongside your MC Scorecard and Lifestyle & Medical History intake forms. Please complete those first. This form covers areas those forms do not — pathogens, co-infections, mold/CIRS, MCAS, POTS, and heavy metal toxicity.
📋 How to Fill Out This Form
Rate each symptom based on how often you experienced it over the last 90 days
For Yes/No questions, select what applies
Scores update automatically — Yellow or Red flags an area for your consultation
★ Hallmark items count double — they are the most clinically significant for that condition
When finished, go to Step 8 — Review & Print to see all your scores
Click Email Results to send your scores and full answers file directly to your practitioner, or use Save to File to keep a copy on your device
You can also Copy Summary to clipboard or Print / Save as PDF
⚠ Important Disclaimer
Higher scores indicate a stronger pattern fit for discussion and possible follow-up — not a diagnosis. Many symptoms overlap across conditions. This form helps guide follow-up questions and testing priorities.
🔒 Your Privacy
Your answers never leave your device. This form runs entirely in your browser — no data is sent to any server, no information is stored in the cloud, and no one can access your responses unless you choose to share them. All data is saved locally on your computer. You decide what to share, when, and with whom — whether that’s saving a file, printing a PDF, or emailing your results. You are in full control of your data.
