Medical Symptoms Questionnaire (MSQ)
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Point Scale:
0 - Never or almost never 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
*
HEAD SCORE
EYES
*
EYES SCORE
EARS
*
EARS SCORE
MOUTH/THROAT
*
MOUTH/THROAT SCORE
SKIN
*
SKIN SCORE
HEART
*
HEART SCORE
LUNGS
*
LUNG SCORE
DIGESTIVE TRACT
*
DIGESTIVE TRACT SCORE
JOINTS/MUSCLES
*
JOINTS/MUSCLES SCORE
WEIGHT
*
WEIGHT SCORE
ENERGY/ACTIVITY
*
ENERGY/ACTIVITY SCORE
MIND
*
MIND SCORE
EMOTIONS
*
EMOTIONS SCORE
OTHER
*
OTHER SCORE
GRAND TOTAL
*
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