Medical Symptoms Quiz

A note from DrB:

There is an epidemic of chronic disease in America, and people are sick and tired of being sick and tired. Most of us power through our lives and ignore small clues our body is giving us that somthing is wrong..It's not normal to have gas. It's not normal to have bloating. It's not normal to have low grade constipation and every once in a while have to run to make it to the bathroom. Your body is trying to tell you something.

Many people (most men) hurry through this form and place 0s where there should be 1s and 1s where there should be 3s. Then in our first visit it comes out that the 0s are not really 0s.

85% of the tests we do are "covered by Medicare" and if Medicare covers a test your insurance should cover the test. IF they allow you to go "out of plan" AND you have the symptoms to warrant getting the test. But if you put all 0s you are saying "I never have those symptoms."

Slow down. Consider filling out this form with your partner. Often that discussion will go something like this:

"Hearburn- Zero Gas- Zero Bloating - Zero"

"What do you mean you never have heartburn. You are practically living on Tums!"

You get the picture.

DrB

Today's Date

MonthDayYear

Legal Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Birthday*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender at Birth*

MaleFemale

Current Gender Identity*

MSQ Total (please leave this blank and your MSQ will total itself)

Headaches*

(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

Faintness*

(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

Dizziness*

(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

Insomnia*

(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

Section Total

Watery or itchy eyes*

(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

Swollen, reddened or sticky eyelids*

(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

Bags or dark circles under eyes*

(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

Blurred or tunnel vision (does not include near or far-sightedness)*

(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

Section Total

Itchy ears*

(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

Earaches, ear infections*

(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

Drainage from ear*

(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

Ringing in ears, hearing loss*

(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

Section Total

Stuffy nose*

(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

Sinus problems*

(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

Hay fever*

(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

Sneezing attacks*

(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

Excessive mucus formation*

(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

Section Total

Chronic coughing*

(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

Gagging, frequent need to clear throat*

(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

Sore throat, hoarseness, loss of voice*

(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

Swollen or discolored tongue, gums, lips*

(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

Canker sores*

(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

Section Total

Acne*

(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

Hives, rashes, dry skin*

(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

Hair loss*

(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

Flushing, hot flashes*

(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

Excessive sweating*

(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

Section Total

Irregular or skipped heartbeat*

(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

Rapid or pounding heartbeat*

(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 pain*

(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

Section Total

Chest congestion*

(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

Asthma, bronchitis*

(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

Shortness of breath*

(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

Difficulty breathing*

(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

Section Total

Nausea, vomiting*

(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

Diarrhea*

(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

Constipation*

(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

Bloated feeling*

(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

Belching, passing gas*

(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

Heartburn*

(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

Intestinal/stomach pain*

(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

Section Total

Pain or aches in joints*

(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

Arthritis*

(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

Stiffness or limitation of movement*

(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 muscles*

(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

Feeling of weakness or tiredness*

(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

Section Total

Binge eating/drinking*

(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

Craving certain foods*

(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

Excessive weight*

(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

Compulsive eating*

(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

Water retention*

(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

Underweight*

(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

Section Total

Fatigue, sluggishness*

(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

Apathy, lethargy*

(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

Hyperactivity*

(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

Restlessness*

(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

Section Total

Poor memory*

(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

Confusion, poor comprehension*

(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 concentration*

(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 physical coordination*

(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

Difficulty in making decisions*

(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

Stuttering or stammering*

(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

Slurred speech*

(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

Learning disabilities*

(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

Section Total

Mood swings*

(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

Anxiety, fear, nervousness*

(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

Anger, irritability, aggressiveness*

(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

Depression*

(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

Section Total

Frequent illness*

(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 or urgent urination*

(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

Genital itch or discharge*

(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

Section Total

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What's Your MSQ?

HEAD

EYES

EARS

NOSE

MOUTH & THROAT

SKIN

HEART

LUNGS

DIGESTIVE TRACT

JOINTS & MUSCLES

WEIGHT

ENERGY & ACTIVITY

MIND

EMOTIONS

OTHER