Indigo Wellness Group
Wellness Symptom
Questionnaire
Rate each symptom based on your typical experience over the past 14 days. Subtle shifts in mood, energy, skin, and sleep are meaningful markers of progress — this questionnaire helps us track them together.
Questionnaire
Point Scale
0
Never or almost never
1
Occasionally — mild effect
2
Occasionally — severe effect
3
Frequently — mild effect
4
Frequently — severe effect
Digestive Tract
total0
Nausea or vomiting
Diarrhea
Constipation
Bloating
Belching or passing gas
Heartburn
Intestinal or stomach pain
Emotions
total0
Mood swings
Anxiety, fear or nervousness
Anger or irritability
Depression or low mood
Feeling overwhelmed
Emotional sensitivity or tearfulness
Energy & Activity
total0
Fatigue or sluggishness
Apathy or lack of motivation
Afternoon energy crash
Relying on caffeine to function
Hyperactivity or restlessness
Sleep
total0
Difficulty falling asleep
Waking during the night
Waking too early and unable to return to sleep
Unrefreshing or non-restorative sleep
Vivid dreams or nightmares
Exhausted despite a full night's sleep
Needing to nap during the day
Stress & Nervous System
total0
Feeling burned out or depleted
Difficulty relaxing or switching off
Feeling wired but tired
Startling easily or feeling on edge
Difficulty coping with everyday stress
Low resilience or emotional tolerance
Hormonal & Menstrual
total0
Irregular or unpredictable cycles
Heavy or painful periods
Spotting between periods
PMS — mood changes before your period
PMS — bloating or breast tenderness
PMS — headaches or cramps
PMS — food cravings before your period
Perimenopausal or menopausal symptoms
Low libido
Increased facial hair or scalp hair thinning
Head
total0
Headaches
Migraines
Faintness or lightheadedness
Dizziness
Brain fog
Joints & Muscles
total0
Pain or aches in joints
Stiffness or limited movement
Pain or aches in muscles
Weakness or heaviness in the body
Mind
total0
Poor memory or forgetfulness
Difficulty concentrating
Confusion or slow thinking
Difficulty making decisions
Poor physical coordination
Mouth & Throat
total0
Chronic coughing
Frequent need to clear throat
Sore throat or hoarseness
Canker sores or mouth ulcers
Nose
total0
Stuffy or runny nose
Sinus congestion or pressure
Seasonal allergies
Sneezing attacks
Excessive mucus
Skin, Hair & Nails
total0
Acne or breakouts
Hives, rashes or eczema
Dry or dull skin
Hair loss or thinning
Brittle or slow-growing nails
Flushing or hot flushes
Excessive sweating
Weight & Appetite
total0
Cravings for sugar or refined carbs
Cravings for salt
Difficulty feeling full or satisfied
Compulsive or emotional eating
Water retention or puffiness
Unexplained weight gain
Poor appetite or forgetting to eat
Other
total0
Frequent illness or low immunity
Slow recovery from illness
Frequent or urgent urination
Urinary tract infections
Genital itch or abnormal discharge
Your WSQ Score
Share this number with your practitioner at each visit to track your progress over time.
0WSQ Total
Score Interpretation
0 – 15Optimal wellness
16 – 39Mild symptom burden
40 – 69Moderate — needs addressing
70+High — needs intervention
Step 2 of 2
Share your score with your provider
Enter your name, provider, and WSQ total in the form below and hit submit — we'll have it on file before your next appointment.
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