Medical Symptoms Questionnaire (MSQ)

Medical Symptoms Questionnaire (MSQ)
Patient Name
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- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
HEAD
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Headaches
Faintness
Dizziness
Insomnia
Total
EYES
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
EARS
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
NOSE
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
MOUTH/THROAT
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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 or discolored tongue, gums, lips
Canker sores
Total
SKIN
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Hives, rashes, dry skin
Acne
Hair loss
Hair loss
Flushing, hot flashes
Excessive sweating
Total
HEART
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)
LUNGS
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Chest congestion
Asthma, bronchitis
Difficulty breathing
Shortness of breath
Total
DIGESTIVE TRACT
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Diarrhea
Constipation
Nausea, vomiting
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total
JOINTS/MUSCLE
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
WEIGHT
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
ENERGY/ACTIVITY
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total
MIND
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects is severe

3 – Frequently have it, effect is not severe

4 – Frequently have it, effect is severe
Poor Memory
Confusion, poor comprehension
Stuttering or Stammering
Poor concentration
Poor physical coordination
Difficulty in making decisions
Slurred speech
learning disabilities
Total
EMOTIONS
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
OTHER
0 – Never or almost never have the symptom

1 – Occasionally have it, effect is not severe

2- Ocassionally have it, effects 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
Grand Total
Should be Empty:

Medical Symptoms Questionnaire (MSQ)

HEAD

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)

LUNGS

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER