Medical Symptoms Questionnaire




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

Past 30 days

Past 48 hours



Point Scale

0 - Never or almost never have the symptoms

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



Body Part Symptoms Point Scale Total
0 1 2 3 4
Head Headaches
Faintness
Dizziness
Insomnia
Eyes 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)
Ears Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears
hearing loss
Nose Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Mouth/Throat Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Skin Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
sweating
Heart Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Lungs Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Digestive Tract Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Joints/Muscle Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness
Weight Binge eating/drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight
Energy/Activity Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Mind Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Emotions Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Other Frequent illness
Frequent or urgent urination
Genital itch or discharge
Grand Total