Medical Symptoms Questionnaire (MSQ)

Medical Symptoms Questionnaire (MSQ)
Name

First NameLast Name
Email
example@example.com
Date

MonthDayYear
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

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
Headaches
Faintness
Dizziness
Insomnia
Total Head

EYES

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
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 Eyes

EARS

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
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total Ears

NOSE

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
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total Nose

MOUTH/THROAT

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
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen of discolored tongue, gums, lips
Canker sores
Total Mouth/Throat

SKIN

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
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Total Skin

HEART

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
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total Heart

LUNGS

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
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total Lungs

DIGESTIVE TRACT

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
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total Digestive Tract

JOINTS/MUSCLE

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
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Total Joints/Muscle

WEIGHT

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
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Total Weight

ENERGY/ACTIVITY

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
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total Energy/Activity

MIND

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
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total Mind

EMOTIONS

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
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total Emotions

OTHER

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
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total Other
Grand Total
Should be Empty: