Medical Symptoms Questionnaire (MSQ)

Medical Symptoms Questionnaire (MSQ) - 2
Name

First NameLast Name
Email*
example@example.com
Date

DayMonthYear
Date
How would you describe your diet

OmnivorePescatarianVegetarianVegan
How many Covid vaccinations have you had?

0123more than 4
Do you take prescribed medications? If so, what are they and what condition are they for?
Do you take any supplements? If so, what are they and what condition are they for?
Do you have any other diagnosed conditions?
What is your history of illnesses? Any food poisoning? Any surgery?
Were you a vaginal birth? Were you breast fed?
What is your antibiotic history? Please state when and why you last took antibiotics?
Do you have any allergies or intolerances?

Rate each of the following symptoms based upon your typical health profile for:

Past 30 daysPast 48 hours

Head

	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
Headaches
Faintness/Dizziness

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
Watery or itchy
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes

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
Itchy
Earaches, ear infections
Ringing in ears, hearing loss

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
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

Mouth/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
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Canker sores

Heart

	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
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Lungs

	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 congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Digestive Tract

	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
Nausea, vomiting
Diarrhoea
Constipation
Bloated feeling
Belching, passing gas
Heartburn/acid reflux
Intestinal/stomach pain

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
Acnes
Hives, rashes, dry skin
Hair loss
Brittle, splitting, ridged nails
Flushing, hot flushes
Excessive sweating

Joints/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
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

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
Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Mind

	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 memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Emotions

	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
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Energy/Activity

	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
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness/cramps
Feel the cold
Insomnia

Other

	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 illness
Frequent or urgent urination
Genital itch or discharge

Total
Grand Total/276
Note that less than 10 = optimal

More than 50 suggests the presence of significant inflammation and/or toxic load problems.

From Toolbox, Institute for Functional Medicine
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Medical Symptoms Questionnaire (MSQ) - 2