Back Section 1 Tell us about your journey and how your health has been affected. Help us understand how your day to day life is affected by your illness. What's your first name?*We use this to personalize your experience. What is your biological sex?* Female Male Prefer Not To Say How Many Healthcare Providers Have You Seen?* 1-3 4-6 7-10 More than 10 See what other people are reporting: What diagnosis have you been given?*Select all the diagnoses that a health care provider has given you. Lyme Disease Long Covid ME/CFS PANS/PANDA Mast Cell (MCAS) Histamine Intolerance Mold Illness CIRS Autoimmune Disorder SIBO or SIFO Fibromyalgia Candida Epstein-Barr Virus Irritable Bowel Syndrome Gut dysbiosis Leaky Gut Adrenal Dysregulation Other How long have you been ill with Lyme Disease?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Long Covid?* 1 Year 1 to 2 Years 3 Years How long have you been ill with ME/CFS?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with PANS/PANDA?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Mast Cell (MCAS)?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Histamine Intolerance?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Mold Illness?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with CIRS?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with an Autoimmune Disorder?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with SIBO or SIFO?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Fibromyalgia?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Candida?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Epstein-Barr Virus?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Irritable Bowel Syndrome?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Gut dysbiosis?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Leaky Gut?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years How long have you been ill with Adrenal Dysregulation?* 1 Year 1 to 3 Years 3 to 5 Years 5 to 10 Years More Than 10 Years Other DiagnosisPlease input the diagnosis you have been given. How would you rate your health over the last 6 months?* Excellent Good Fair Not Good Terrible See what other people are reporting: How much of the time does your health interfere with your social activities?* Not At All Slightly Somewhat Considerably Extremely See what other people are reporting: How much of the time does your health interfere with work or school?* Not At All Slightly Somewhat Considerably Extremely See what other people are reporting: How much does your health limit your physical activities?* Not At All Slightly Somewhat Considerably Extremely See what other people are reporting: How much does pain interfere with your daily activities?* Not At All Slightly Somewhat Considerably Extremely See what other people are reporting: How often are you able to exercise weekly?* Not At All 1 to 2 times 3 to 5 times More than 5 times See what other people are reporting: Section 2 Give us an overview of your symptoms. Help us understand your overall health by telling us how you've been feeling recently. What gastrointestinal symptoms are your experiencing?*Select all the symptoms that you have had over the last 6 months. Bloating Abdominal Pain Nausea Vomiting Heartburn or relflux Gerd Diarrhea Constipation Excessive Gas Motility issues IBS SIBO or SIFO No symptoms Other Please input other gastrointestinal symptoms you are experiencing.Please input other gastrointestinal symptoms you are experiencing. How severe is your bloating?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your abdominal pain?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your nausea?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your vomiting?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your heartburn or relflux?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your gerd?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your diarrhea?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your constipation?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your excessive gas?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe are your motility issues?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your IBS?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your SIBO or SIFO?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe are your other gastrointestinal symptoms?* 1 2 3 4 5 6 7 8 9 10 Select Severity What neurological symptoms are your experiencing?*Select all the symptoms that you have had over the last 6 months. Headaches or migraines Weakness Numbness or tingling Sleep disturbances Memory Changes Brain Fog Trouble with Concentration Facial Palsy Visual Disturbances Neuropathy Depression Anxiety No Symptoms Other Please input other neurological symptoms you are experiencing.Please input other neurological symptoms you are experiencing. How severe are your headaches or migranes?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your weakness?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your numbness or tingling?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your sleep disturbances?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe are your memory changes?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your brain fog?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your trouble with concentration?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your facial palsy?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe are your visual disturbances?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your neuropathy?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your depression?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your anxiety?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe are your other neurological symptoms?* 1 2 3 4 5 6 7 8 9 10 Select Severity What metabolic symptoms are your experiencing?Select all the symptoms that you have had over the last 6 months. Loss of Motivation Abnormal Weight Gain or Loss Intolerance to Cold or Heat Dizziness Increased Thirst and Urination Excessive Hunger Vision Changes High Fasting Glucose No Symptoms Other Please input other metabolic symptoms you are experiencing.Please input other metabolic symptoms you are experiencing. How severe is your loss of motivation?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of abnormal weight gain or loss?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of intolerance to cold or heat?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of dizziness?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of increased thirst and urination?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of excessive hunger?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of vision changes?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your loss of high fasting glucose?* 1 2 3 4 5 6 7 8 9 10 Select SeverityHow severe is your other metabolic symptom?* 1 2 3 4 5 6 7 8 9 10 Select Severity What skin symptoms are your experiencing?Select all the symptoms that you have had over the last 6 months. Unusual Rashes Bulls-eye Rash Eczema Psoriasis Itchy Skin No Symptoms Other Please input other skin symptoms you are experiencing.Please input other skin symptoms you are experiencing. Neurological Symptoms A Few More Sections To GoYour Symptom Score {quiz_score} ResearchHow much research do you do about your illness? Well Informed Some Research No Research What if it could help you get better?*Are you willing to think outside your diagnosis? Yes No Maybe Your Email*Your results will be sent to your email address. Enter Email Confirm Email By giving Chronix your email address, you consent to be contacted by us with informational or service-related communications. You may unsubscribe at any time. CommentsPlease let us know what's on your mind. Have a question for us? Ask away.
