Medical Symptom Questionnaire

Physical Therapy Studio

Medical Symptom Questionnaire
Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rate each of the following symptoms based upon your typical health profile for:
Point Scale 0- Never or almost never have the symptoms

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
Insomnia
Dizziness
Total
Digestive Tract
Intestinal/stomach pain
Diarrhea
Nausea, vomiting
Belching, passing gas
Constipation
Heartburn
Bloated feeling
Total
Eyes
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles undereye
Blurred or tunnel vision (does no include near/far sightedness)
Total
Joint/Muscles
Pain or aches in muscles
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Total
EARS
Earaches, ear infections
Itchy ears
Drainage from ear
Ringing in ears, hearing loss
Total
WEIGHT
Binge eating/drinking
Water retention
Compulsive eating
Excessive weight
Underweight
Craving certain foods
Total
NOSE
Stuffy nose
Hay fever
Sneezing attacks
Excessive mucus formation
Total
Mouth and Throat
Sore throat, hoarseness loss of voice Swollen or discolored tongue, gums or lips
Chronic coughing
Gagging, frequent need to clear throat
Total
Energy/Activity
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Cankersores
Total
Mind
Poor concentration
Slurred speach
Stuttering or stammering
Poor memory
Confusion, poor comprehension
Poor physical coordination
Difficulty in making decisions
Learning disabilities
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
Emotions
Mood swings
Anger, irritability, aggressiveness
Depression
Anxiety, fear, nervousness
Total
Lungs
Asthma, bronchitis
Chest congestion
Shortness of breath
Difficulty breathing
Total
Other
Frequent or urgent urination
Frequent illness
Genital itch or discharge
Total
Grand Total
Should be Empty:

Physical Therapy Studio

Head

Digestive Tract

Eyes

Joint/Muscles

EARS

WEIGHT

NOSE

Mouth and Throat

Energy/Activity

Mind

Skin

Heart

Emotions

Lungs

Other