• Medical Symptom Questionnaire

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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

  • Past*
    • Head 
    • Headaches*
    • Faintness*
    • Dizziness*
    • Insomnia*
    • 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 farsightedness)*
    • Ears 
    • Itchy ears*
    • Earaches, ear infections*
    • Bags or dark circles under eyes*
    • Blurred or tunnel vision (does not include near- or farsightedness)*
    • Nose 
    • Stuffy Nose*
    • Sinus problems*
    • Hay fever*
    • Sneezing attacks*
    • Excessive mucus formation*
    • Mouth/Throat 
    • Chronic coughing*
    • Gagging, frequent need to clear throat*
    • Sore throat, hoarseness, loss of voice*
    • Swollen or discolored tongue, gums or lips*
    • Canker sores*
    • Skin 
    • Acne*
    • Hives, rashes, dryskin*
    • Hair loss*
    • Flushing, hotflashes*
    • Excessive sweating*
    • Heart 
    • Irregular or skipped heartbeat*
    • Rapid or pounding heartbeat*
    • Chest pain*
    • Lungs 
    • Chest congestion*
    • Asthma, bronchitis*
    • Shortness of breath*
    • Difficulty breathing*
    • Digestive Tract 
    • Nausea, vomiting*
    • Diarrhea*
    • Constipation*
    • Bloated feeling*
    • Belching, passing gas*
    • Heartburn*
    • Intestinal/stomach pain*
    • Joints/Muscles 
    • Pain or aches in joints*
    • Arthritis*
    • Stiffness or limitation of movement*
    • Pain or aches in muscles*
    • Feeling of weakness or tiredness*
    • Weight 
    • Binge eating/drinking*
    • Craving certain food*
    • Excessive weight*
    • Compulsive eating*
    • Water retention*
    • Underweight*
    • Energy/Activity 
    • Fatigue, sluggishness*
    • Apathy, lethargy*
    • Hyperactivity*
    • Restlessness*
    • Mind 
    • Poor memory*
    • Confusion, poor comprehension*
    • Poor concentration*
    • Poor physical coordination*
    • Difficulty in making decisions*
    • Stuttering or stammering*
    • Slurred speech*
    • Learning disabilities*
    • Emotions 
    • Mood swings*
    • Anxiety, fear, nervousness*
    • Anger, irritability, aggressiveness*
    • Depression*
    • Other 
    • Frequent illness*
    • Frequent or urgent urination*
    • Genital itch or discharge*
    • Grand Total and Submit 
    • Date
       - -
      2 digit month, 2 digit day, 4 digit year
    •  p. 443.979.7171 AAA Physical Therapy, LLC
      admin@AAAPhysicalTherapy.com
      8975 Guilford Rd Ste 170 Columbia, MD 21046      		  f. 667.200.5908

       

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