MSQ Medical Symptoms Questionnaire (MSQ) MedicalPlease enable JavaScript in your browser to complete this form. - Step 1 of 3Patient Name *FirstLastRate each of the following symptoms based upon your typical health profile for the past 14 days. Point Scale0 - Never or almost never have the symptom1 - Occasionally have it, effect is not severe2 - Occasionally have it, effect is severe3 - Frequently have it, effect is not severe4 - Frequentlyhave it, effect is severeHEADHeadaches Selected Value: 0 Faintness Selected Value: 0 Dizziness Selected Value: 0 Insomnia Selected Value: 0 TOTAL:EYESWatery or itchy eyes Selected Value: 0 Swollen, reddened or sticky eyelids Selected Value: 0 Bags or dark circles under eyes Selected Value: 0 Blurred or tunnel vision (Does not include near or far-sightedness) Selected Value: 0 TOTAL:EARSItchy ears Selected Value: 0 Hearing loss Selected Value: 0 Ear infections Selected Value: 0 Drainage from ear Selected Value: 0 Hearing loss Selected Value: 0 TOTAL:NOSEStuffy nose Selected Value: 0 Sinus problems Selected Value: 0 Hay fever Selected Value: 0 Sneezing attacks Selected Value: 0 Excessive mucus formation Selected Value: 0 TOTAL:MOUTH/THROATChronic coughing Selected Value: 0 Gagging, frequent need to clear throat Selected Value: 0 Sore throat, hoarseness, loss of voice Selected Value: 0 Swollen or discoloured tongue, gums, lips Selected Value: 0 Canker sores Selected Value: 0 TOTAL: SKINAcne Selected Value: 0 Hives, rashes, dry skin Selected Value: 0 Hair loss Selected Value: 0 Flushing, hot flashes Selected Value: 0 Excessive sweating Selected Value: 0 TOTAL:NextHEARTIrregular or skipped heartbeat Selected Value: 0 Rapid or pounding heartbeat Selected Value: 0 Chest pain Selected Value: 0 TOTAL: LUNGSChest congestion Selected Value: 0 Asthma, bronchitis Selected Value: 0 Shortness of breath Selected Value: 0 Difficulty breathing Selected Value: 0 TOTAL: GIGESTIVE TRACTNausea, vomiting Selected Value: 0 Diarrhoea Selected Value: 0 Constipation Selected Value: 0 Belching, passing gas Selected Value: 0 Bloated feeling Selected Value: 0 Heartburn Selected Value: 0 Intestinal/stomach pain Selected Value: 0 TOTAL: JOINTS/MUSCLEPain or aches in joint Selected Value: 0 Arthritis Selected Value: 0 Stiffness or limitation of movement Selected Value: 0 Pain or aches in muscles Selected Value: 0 Feeling of weakness or tired Selected Value: 0 TOTAL: WEIGHTBinge eating/drinking Selected Value: 0 Craving certain foods Selected Value: 0 Water retention Selected Value: 0 Underweight Selected Value: 0 TOTAL: ENERGY/ACTIVITYFatigue, sluggishness Selected Value: 0 Apathy, lethargy Selected Value: 0 Hyperactivity Selected Value: 0 Restlessness Selected Value: 0 Anxiety, fear, nervousness Selected Value: 0 TOTAL: EMOTIONMood swings Selected Value: 0 Anxiety, fear, nervousness Selected Value: 0 Anger, irritability, aggressiveness Selected Value: 0 Depression Selected Value: 0 TOTAL:NextMINDPoor memory Selected Value: 0 Confusion, poor comprehension Selected Value: 0 Poor concentration Selected Value: 0 Poor physical coordination Selected Value: 0 Difficulty in making decisions Selected Value: 0 Stuttering or stammering Selected Value: 0 Slurred speech Selected Value: 0 Learning disailities Selected Value: 0 TOTAL: OTHERSFrequent illness Selected Value: 0 Frequent or urgent urination Selected Value: 0 Genital itch or discharge Selected Value: 0 TOTAL: Submit