Medical Symptoms Questionnaire (MSQ)

Mid Coast Integrative Health- Medical Symptoms Questionnaire (MSQ)
Patient Name
Date Of Birth

DayMonthYear
Date
Date

DayMonthYear
Date
Instructions
Use this point scale to rate each of the following symptoms based on your typical health profile for the past 14 days:
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
Headaches
Faintness
Dizziness
Insomnia
Total
Eyes
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (doesn't include nearsightedness or farsightedness)
Total
Ears
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total
Nose
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total
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