Medical Symptom Questionnaire

Patient Name*

First NameLast Name

Patient Date of Birth *

Date

Appointment Date*

Date

MSQ - Medical Symptom/Toxicity Questionnaire identifies symptoms that highlight the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are taking after the first time, record your symptoms for only the last 48 hours.

Point Scale:

0 - Never or almost Never have the symptom

1 - Occasionally have it, effect is not sever

2 - Occasionally have it, effect is severe

3 - Frequently have it, effect is not severe

4 - Frequently have it, effect is severe

HEAD

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia

HEAD TOTAL

EYES

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Watery/Itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

EYES TOTAL

EARS

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss

EARS TOTAL

NOSE

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation

NOSE TOTAL

MOUTH/THROAT

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

MOUTH/THROAT TOTAL

SKIN

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

SKIN TOTAL

HEART

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

HEART TOTAL

LUNGS

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

LUNGS TOTAL

DIGESTIVE TRACT

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

DIGESTIVE TRACT TOTAL

JOINTS/MUSCLE

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

JOINTS/MUSCLE TOTATL

WEIGHT

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

WEIGHT TOTAL

ENERGY/ACTIVITY

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

ENERGY/ACTIVITY TOTAL

MIND

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

MIND TOTAL

EMOTIONS

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

EMOTIONS TOTAL

OTHER

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

OTHER TOTAL

MSQ GRAND TOTAL