Medical Symptoms Questionnaire (MSQ)

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale

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 (Does not include near or far-sightedness) :

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:

MOUTH/THROAT

Chronic coughing :

Gagging, frequent need to clear throat :

Sore throat, hoarseness, loss of voice :

Swollen or discolored tongue, gums, lips :

Canker sores :

TOTAL:

SKIN

Acne :

Hives, rashes, dry skin :

Hair loss :

Flushing, hot flashes :

Excessive sweating :

TOTAL:

HEART

Irregular or skipped heartbeat :

Rapid or pounding heartbeat :

Chest pain :

TOTAL:

LUNGS

Chest congestion :

Asthma, bronchitis :

Shortness of breath :

TOTAL:

DIGESTIVE TRACT

Nausea, vomiting :

Diarrhea :

Constipation :

Bloated feeling :

Belching, passing gas :

Heartburn :

Intestinal/stomach pain :

TOTAL:

JOINTS/MUSCLE

Pain or aches in joints :

Arthritis :

Stiffness or limitation of movement :

Pain or aches in muscles :

Feeling of weakness or tiredness :

TOTAL:

WEIGHT

Binge eating/drinking :

Craving certain foods :

Excessive weight :

Compulsive eating :

Water retention :

Underweight :

TOTAL:

ENERGY/ACTIVITY

Fatigue, sluggishness :

Apathy, lethargy :

Hyperactivity :

Restlessness :

TOTAL:

MIND

Poor memory :

Confusion, poor comprehension :

Poor concentration :

Poor physical coordination :

Difficulty in making decisions :

Stuttering or stammering :

Slurred speech :

Learning disabilities :

TOTAL:

EMOTIONS

Mood swings :

Anxiety, fear, nervousness :

Anger, irritability, aggressiveness :

Depression

TOTAL:

OTHER

Frequent illness :

Frequent or urgent urination :

Genital itch or discharge :

TOTAL:

Grand Total

Rate each of the following symptoms based upon your typical health profile for the past 14 days.

Point Scale

HEAD

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

LUNGS

DIGESTIVE TRACT

JOINTS/MUSCLE

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

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