MSQ Questionnaire

Medical Symptom/Toxicity Questionnaire (MSQ)

The MSQ identifies symptoms that help to determine the underlying causes of illness, and helps you track your progress over time. If you are completing this questionnaire for the first time, please record your symptoms over the last 48 hours. If you have completed this questionnaire with us previously, please rate your symptoms from the last 30 days.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rate each of the following symptoms for the specified duration:
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

HEAD

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia

HEAD TOTAL

EYES

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Watery/Itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

EYES TOTAL

EARS

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss

EARS TOTAL

NOSE

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation

NOSE TOTAL

MOUTH/THROAT

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

MOUTH/THROAT TOTAL

SKIN

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

SKIN TOTAL

HEART

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

HEART TOTAL

LUNGS

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

LUNGS TOTAL

DIGESTIVE TRACT

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

DIGESTIVE TRACT TOTAL

JOINTS/MUSCLE

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

JOINTS/MUSCLE TOTATL

WEIGHT

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

WEIGHT TOTAL

ENERGY/ACTIVITY

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

ENERGY/ACTIVITY TOTAL

MIND

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

MIND TOTAL

EMOTIONS

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

EMOTIONS TOTAL

OTHER/MISC

Rows	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

OTHER/MISC TOTAL
GRAND TOTAL
Key to MSQ:

Less than 10: Optimal

10 - 50: Mild Toxicity

50 - 100: Moderate Toxicity

100 or more: Severe Toxicity

IntellxxDNA Agreement
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Your DNA contains variants, or SNPs (single nucleotide polymorphisms), that may signal potential benefits as well as risks. Your DNA is not your destiny. In fact, understanding your genomic profile empowers you to make intelligent health and wellness choices now that may impact your future quality of life. Your doctor will review your genomic profile as one of several factors of consideration when making clinical decisions to help you achieve optimal health.*
IntellxxDNA tests are not billable to insurance, are non-refundable, and cannot be transferred to another patient.
IntellxxDNA genomic reports are non-diagnostic.
IntellxxDNA is not a lab. Your specimen will be processed at third-party CLIA/CAP certified lab anonymously.
Patients cannot mail their specimen from the state of New York. Patients will be instructed to mail their specimen from outside of New York, for example, New Jersey, or Connecticut.
Due to the complexity of the tests performed in functional medicine, your doctor cannot answer questions about the results outside of a scheduled appointment.
By signing below, I acknowledge that my doctor or her staff has informed me of the out-of-pocket cost associated with the IntellxxDNA test. I confirm my understanding of this cost and consent to proceed with the test. I agree to the terms outlined above and authorize Healing Family Functional Medicine to use my credit card for payment on the IntellxxDNA provider portal. I understand that this payment is non-refundable and the transaction cannot be undone once processed.
Should be Empty:

Medical Symptom/Toxicity Questionnaire (MSQ)

IntellxxDNA Agreement