Medical Symptoms Questionnaire
Name
First Name
Last Name
Rate each of the following symptoms based on the last 48 hours:
Point Scale
0 Never or almost never have the symptom
3 Frequently have it, effect is not severe
1 Occasionally have it, effect is not severe
4 Frequently have it, effect is severe
2 Occasionally have it, effect is severe
HEAD
Headaches
Please Select
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
Please Select
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
Please Select
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
Please Select
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 TOTAL
EYES
Watery or itchy eyes
Please Select
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, red or sticky eyelides
Please Select
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
Please Select
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
Please Select
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
EYES TOTAL
EARS
Itchy ears
Please Select
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
Please Select
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
Please Select
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
Please Select
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
EARS TOTAL
NOSE
Stuffy Nose
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
NOSE TOTAL
MOUTH/THROAT
Chronic Coughing
Please Select
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, need to clear throat
Please Select
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, Hoarse, Loss of Voice
Please Select
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 or Lips
Please Select
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
Please Select
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
MOUTH/THROAT TOTAL
SKIN
Acne
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
SKIN TOTAL
HEART
Irregular or Skipped Heartbeat
Please Select
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
Please Select
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
Please Select
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
HEART TOTAL
LUNGS
Chest Congestion
Please Select
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
Please Select
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
Please Select
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
Please Select
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
LUNGS TOTAL
DIGESTIVE TRACT
Nausea, Vomiting
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
DIGESTIVE TRACT TOTAL
JOINTS/MUSCLE
Pain or Aches in Joints
Please Select
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
Please Select
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
Stiff or Limitation of Movement
Please Select
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
Please Select
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 Tired
Please Select
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
JOINTS/MUSCLE TOTAL
WEIGHT
Binge Eating/Drinking
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
WEIGHT TOTAL
ENERGY/ACTIVITY
Fatigue, Sluggishness
Please Select
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
Please Select
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
Please Select
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
Please Select
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
ENERGY/ACTIVITY TOTAL
MIND
Poor Memory
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
Please Select
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
MIND TOTAL
EMOTIONS
Mood Swings
Please Select
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
Please Select
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, Aggression
Please Select
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
Please Select
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
EMOTIONS TOTAL
OTHER
Frequent Illness
Please Select
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
Please Select
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
Please Select
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
OTHER TOTAL
GRAND TOTAL
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