Medical Symptoms Questionnaire (MSQ)


    Date
    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
    Point Scale
    0 – Never or almost never have the symptom
    1 – Occasionally have it, effect is not severe
    2 – Occasionally have it, effect is severe
    3 – Frequently have it, effect is not severe
    4 – Frequently have it, effect is severe
    HEAD
    Headaches :
    Faintness :
    Dizziness :
    Insomnia :
    Total :
    EYES
    Watery or itchy eyes :
    Swollen, reddened or sticky eyelids :
    Bags or dark circles under eyes :
    Blurred or tunnel vision
    (Does not include near or far-sightedness) :
    Total :
    EARS
    Itchy ears :
    Earaches, ear infections :
    Drainage from ear :
    Ringing in ears, hearing loss :
    Total :
    NOSE
    Stuffy nose :
    Sinus problems :
    Hay fever :
    Sneezing attacks :
    Excessive mucus formation :
    Total :
    MOUTH/THROAT
    Chronic coughing :
    Gagging, frequent need to clear throat :
    Sore throat, hoarseness, loss of voice :
    Swollen or discolored tongue, gums, lips :
    Canker sores :
    Total :
    SKIN
    Acne :
    Hives, rashes, dry skin :
    Hair loss :
    Flushing, hot flashes :
    Excessive sweating :
    Total :
    HEART
    Irregular or skipped heartbeat :
    Rapid or pounding heartbeat :
    Chest pain :
    Total :
    LUNGS
    Chest congestion :
    Asthma, bronchitis :
    Shortness of breath :
    Total :
    DIGESTIVE TRACT
    Nausea, vomiting :
    Diarrhea :
    Constipation :
    Bloated feeling :
    Belching, passing gas :
    Heartburn :
    Intestinal/stomach pain :
    Total :
    JOINTS/MUSCLE
    Pain or aches in joints :
    Arthritis :
    Stiffness or limitation of movement :
    Pain or aches in muscles :
    Feeling of weakness or tiredness :
    Total :
    WEIGHT
    Binge eating/drinking :
    Craving certain foods :
    Excessive weight :
    Compulsive eating :
    Water retention :
    Underweight :
    Total :
    ENERGY/ACTIVITY
    Fatigue, sluggishness :
    Apathy, lethargy :
    Hyperactivity :
    Restlessness :
    Total :
    MIND
    Poor memory :
    Confusion, poor comprehension :
    Poor concentration :
    Poor physical coordination :
    Difficulty in making decisions :
    Stuttering or stammering :
    Slurred speech :
    Learning disabilities :
    Total :
    EMOTIONS
    Mood swings :
    Anxiety, fear, nervousness :
    Anger, irritability, aggressiveness :
    Depression :
    Total :
    OTHER
    Frequent illness :
    Frequent or urgent urination :
    Genital itch or discharge :
    Total :
    Grand Total