CIRS SYMPTOM QUESTIONNAIRE

Thank you for your interest in our CIRS (Chronic Inflammatory Response Syndrome) evaluation. Please complete this brief form to begin the assessment process.

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Welcome to our CIRS (Chronic Inflammatory Response Syndrome) Symptom Assessment. This checklist will help identify if your symptoms may be related to CIRS. Please complete all sections accurately.

Note: This assessment is for screening purposes only and is not intended to diagnose any medical condition.

Please select all symptoms you've experienced regularly

over the past 3 months

Neurological Symptoms

Fatigue

Weakness

Decreased assimilation of new knowledge

Memory issues

Word-finding difficulties

Concentration issues

Confusion

Disorientation

Tremor

Parkinson's-like symptoms

Multiple Sclerosis

Dementia-like symptoms

Pain & Sensory Symptoms

Body aches

Headache

Light sensitivity

Joint pain

Morning stiffness

Cramps

Unusual skin sensation

Tingling

Numbness

Unusual pains

Abdominal pain

Respiratory & MCAS Symptoms

Shortness of breath

Sinus congestion

Cough

Mast Cell Activation Syndrome

Allergic-type reactions

Digestive & Metabolic Symptoms

Appetite swings

Weight gain

Diarrhea

Leaky gut

Metallic taste

Vision & Eye-Related Symptoms

Red eyes

Blurred vision

Excessive tearing

Mood & Psychiatric Symptoms

Mood swings

Anxiety

Depression

Autonomic Nervous System Symptoms

Excessive thirst

Body temperature regulation issues

Urinary frequency

Sweating

Static shock

Vertigo

Systemic Conditions

Autoimmune disease

ME/CFS (Myalgic Encephalomyelitis/Chronic Fatigue Syndrome)

Fibromyalgia

CIRS Symptom Score

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