Medical Symptoms Questionnaire

Patient Name_________________________    Date ________ 

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 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-sighted)                                                                                            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, or 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

                             _______    Difficulty Breathing                                                                                                             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 Condition

                             _______    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  ________