Clone of Medical Symptoms Questionnaire

Medical Symptoms Questionnaire
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Full Name*

First NameLast Name
Instructions - Check each of the following symptoms you are currently experiencing
Head

Headaches or MigrainesFaintnessDizzinessInsomnia
Eyes

Watery or itchy eyesSwollen, reddened, or sticky eyelidsBags or dark circles under eyesBlurred or tunnel vision (doesn’t include nearsightedness or farsightedness)
Nose

Stuffy noseSinus problemsHay feverSneezing attacksExcessive mucus formation
Weight

Binge eating or drinkingCraving certain foodsExcessive weightCompulsive eatingWater retentionUnderweightInability to lose weight
Mind

Poor MemoryConfusion, poor comprehensionPoor concentrationPoor physical coordinationDifficulty in making decisionsStuttering or stammeringSlurred speechLearning disabilities
Skin

AcneHives, rashes, dry skinHair lossFlushing, hot flashesNight SweatsExcessive sweatingCold all the timeDry and wrinkled skin
Heart

Irregular or skipped heartbeatRapid or pounding heartbeatChest pain
Emotions

Mood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepression
Lungs

Chest congestionAsthma, bronchitisShortness of breathDifficulty breathing
Digestive Tract

Nausea, vomitingDiarrheaConstipationBloated feelingBelching, passing gasHeartburnIntestinal or stomach pain
Joints and Muscles

Pain or aches in jointsArthritisStiffness or limitation of movementPain or aches in musclesFeeling of weakness or tiredness
Ears

Itchy earsEaraches, ear infectionsDrainage from earRinging ears, hearing loss
Mouth and Throat

Chronic coughingGagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen or discolored tongue, gums, lipsCanker sores
Energy or Activity

Fatigue, sluggishnessApathy, lethargyHyperactivityRestlessnessDecreased muscle strength
Other

Frequent illnessFrequent or urgent urinationLoss or urine/incontinenceGenital itch or discharge
Male Sexual Health

Decreased sex drive/low libidoDifficult to climax sexuallyDecreased morning erectionsInfrequent or absent ejaculationsNo results from ED medications
Female Sexual Health

Decrease sex drive/low libidoDifficult to climax sexuallyVaginal laxityVaginal dryness
If none of the symptoms apply to you, please state below:
List the symptoms you are most concerned about:
Should be Empty: