Biotics Research MSQ Questionnaire

Biotics Research MSQ Questionnaire

Health Coach Indy
Full Name

First NameLast Name
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Directions:

Rate each of the following symptoms based upon your health profile for the past 30 days. If you are taking after the first time, record your symptoms for the last 48 hours ONLY.
POINT SCALE
0 = Never or almost never have the symptom
1 = Occasionally, effect is not severe
2 = 0ccasionally, effect is severe
3 = Frequently, effect is not severe
4 = Frequently, effect is severe

Digestive Tract

Ears

Emotions

Rows	0	1	2	3	4
Mood Swings
Anxiety, fear or nervousness
Anger, irritability, or aggressiveness
Depression

Energy/Activity

Eyes

Rows	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near-or-far sightedness)

Head

Heart

Rows	0	1	2	3	4
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Joints/Muscles

Rows	0	1	2	3	4
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Lungs

Mind

Rows	0	1	2	3	4
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficult in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Mouth/Throat

Rows	0	1	2	3	4
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen/discolored tongue, gum, lips
Canker sores

Nose

Skin

Weight

Other

Rows	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Directions: