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
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
Headache
0
1
2
3
4
Dizziness
0
1
2
3
4
Faintness
0
1
2
3
4
Insomnia
0
1
2
3
4
HEAD SCORE
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EYES
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
Itchy/Watery Eyes
0
1
2
3
4
Swollen, Red or Sticky Eyelids
0
1
2
3
4
Bags or Dark Circle
0
1
2
3
4
Blurred or Tunnel Vision
0
1
2
3
4
EYES SCORE
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EARS
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
Itchy Ears
0
1
2
3
4
Drainage From Ears
0
1
2
3
4
Earaches/Infections
0
1
2
3
4
Ringing in Ears, Hearing Loss
0
1
2
3
4
EARS SCORE
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MOUTH/THROAT
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
Chronic Coughing
0
1
2
3
4
Sore Throat, Hoarseness, Loss of Voice
0
1
2
3
4
Gagging, Frequent Need to Clear Throat
0
1
2
3
4
Swollen, Discolored Tongue, Gums or Lips
0
1
2
3
4
Canker Sores
0
1
2
3
4
MOUTH/THROAT SCORE
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SKIN
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
Acne
0
1
2
3
4
Hives, Rash, Dry Skin
0
1
2
3
4
Excessive Sweating
0
1
2
3
4
Hair Loss
0
1
2
3
4
Flushing, Hot Flashes
0
1
2
3
4
SKIN SCORE
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HEART
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
Irregular or Skipped Heartbeat
0
1
2
3
4
Chest Pain
0
1
2
3
4
Rapid or Pounding Heartbeat
0
1
2
3
4
HEART SCORE
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LUNGS
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
Chest Congestion
0
1
2
3
4
Shortness of Breath
0
1
2
3
4
Asthma
0
1
2
3
4
Difficulty Breathing
0
1
2
3
4
Bronchitis
0
1
2
3
4
LUNG SCORE
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DIGESTIVE TRACT
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
Nausea, Vomiting
0
1
2
3
4
Diarrhea
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated Feeling
0
1
2
3
4
Belching, Passing Gas
0
1
2
3
4
Heartburn
0
1
2
3
4
Intestinal/Stomach Pain
0
1
2
3
4
DIGESTIVE TRACT SCORE
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JOINTS/MUSCLES
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
Pain or Aches in Joints
0
1
2
3
4
Pain or Aches in Muscles
0
1
2
3
4
Arthritis
0
1
2
3
4
Stiffness or Limitation of Movement
0
1
2
3
4
Feeling of Weakness or Tiredness
0
1
2
3
4
JOINTS/MUSCLES SCORE
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WEIGHT
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
Binge Eating/Drinking
0
1
2
3
4
Compulsive Eating
0
1
2
3
4
Craving Certain Foods
0
1
2
3
4
Water Retention
0
1
2
3
4
Excessive Weight
0
1
2
3
4
Underweight
0
1
2
3
4
WEIGHT SCORE
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ENERGY/ACTIVITY
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
Fatigue, Sluggishness
0
1
2
3
4
Apathy, Lethargy
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Restlessness
0
1
2
3
4
ENERGY/ACTIVITY SCORE
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MIND
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
Poor Memory
0
1
2
3
4
Difficulty in Making Decisions
0
1
2
3
4
Confusion, Poor Comprehension
0
1
2
3
4
Stuttering or Stammering
0
1
2
3
4
Poor Concentration
0
1
2
3
4
Slurred Speech
0
1
2
3
4
Poor Physical Coordination
0
1
2
3
4
Learning Disabilities
0
1
2
3
4
MIND SCORE
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EMOTIONS
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
Mood Swings
0
1
2
3
4
Anger, Irritability, Aggressiveness
0
1
2
3
4
Anxiety, Fear, Nervousness
0
1
2
3
4
Depression
0
1
2
3
4
EMOTIONS SCORE
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OTHER
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
Frequent Illness
0
1
2
3
4
Frequent or Urgent Urination
0
1
2
3
4
Genital Itching or Discharge
0
1
2
3
4
OTHER SCORE
GRAND TOTAL
*
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