Medical Symptoms Questionnaire (MSQ)

Medical Symptoms Questionnaire (MSQ)
Today's Date

Month Day Year
Date
Patient Name *
Height
Weight
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
Head Total
EYES
Watery or itchy eyes
Swollen, reddened
Bags or dark circles under eyes
Blurred or tunnel vision
(Does not include near or far-sightedness)
Eyes Total
EARS
Itchy Ears
Earaches, ear infections
Drainage from ear
Ringing in ear; hearing loss
Ears Total
NOSE
Stuffy nose
Sinus problems
Hay fever
Sneezing Attacks
Excessive mucus formation
Nose Total
MOUTH/THROAT
Chronic coughing
Gagging; Frequent need to clear throat
Soar throat; Hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Mouth Total
SKIN
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Skin Total
HEART
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Heart Total
MEDICAL SYMPTOMS QUESTIONNAIRE (MSQ)
Lungs
Chest congestion
Asthma, Bronchitis
Shortness of breath
Difficulty breathing
Lung Total
Digestive Tract
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/ stomach pain
Digestive Tract Total
Joints/Muscle
Pains or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Joints/Muscle Total
Weight
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Weight Total
Energy/Activity
Fatigue/ sluggishness
Apathy/ lethargy
Hyperactivity
Restlessness
Energy/ Activity Totals
Mind
Poor memory
Confusion, poor comprehension
Poor concetration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disablities
Mind Totals
Emotions
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Emotions Total
Other
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Other 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