Medical Symptoms Questionnaire (MSQ)

Full Name

Date Picker

Instructions:

Use this point scale to rate each of the following symptoms based on your typical health profile for the last 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 not severe

Head

Headaches
Faintness
Dizziness
Insomnia

Head Score

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)

Eyes Score

Ears

Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss

Ears Score

Nose

Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

Nose Score

Use this point scale to rate each of the following symptoms based on your typical health profile for the last 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 not severe

Mouth and Throat

Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

Mouth and Throat Score

Skin

Acne
Hives, rashes, dry skin
Hair loss
Flushing, Hot Flushes
Excessive sweating

Skin Score

Heart

Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Heart Score

Lungs

Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty Breathing

Lungs Score

Digestive Tract

Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal or stomach pain

Digestive Tract Score

Joints and Muscles

Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Joint and Muscles Score

Use this point scale to rate each of the following symptoms based on your typical health profile for the last 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 not severe

Weight

Binge eating or drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Weight Score

Energy or Activity

Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

Energy or Activity Score

Mind

Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Mind Score

Emotions

Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Emotion Score

Other

Frequent illness
Frequent or urgent urination
Genital itch or discharge

Other Score

Total MSQ Score: