MEDICAL SYMPTOMS QUESTIONNAIRE

April 3, 2024 by Tash

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, effect is severe

3 = Frequently have it, effect is not severe

4 = Frequently have it, effect is severe

"*" indicates required fields

Name*

First Last

Email*

Digestive Tract

Nausea or vomiting*

Please enter a number from 0 to 4.

Diarrhea*

Please enter a number from 0 to 4.

Constipation*

Please enter a number from 0 to 4.

Bloated feeling*

Please enter a number from 0 to 4.

Belching or passing gas*

Please enter a number from 0 to 4.

Heartburn*

Please enter a number from 0 to 4.

Intestinal/Stomach pain*

Please enter a number from 0 to 4.

Total

Ears

Itchy ears*

Please enter a number from 0 to 4.

Earaches, ear infections*

Please enter a number from 0 to 4.

Drainage from ear*

Please enter a number from 0 to 4.

Ringing in ears, hearing loss*

Please enter a number from 0 to 4.

Total

Emotions

Mood swings*

Please enter a number from 0 to 4.

Anxiety, fear or nervousness*

Please enter a number from 0 to 4.

Anger, irritability or aggressiveness*

Please enter a number from 0 to 4.

Depression*

Please enter a number from 0 to 4.

Total

Energy/Activity

Fatigue, sluggishness*

Please enter a number from 0 to 4.

Apathy, lethargy*

Please enter a number from 0 to 4.

Hyperactivity*

Please enter a number from 0 to 4.

Restlessness*

Please enter a number from 0 to 4.

Total

Eyes

Watery or itchy eyes*

Please enter a number from 0 to 4.

Swollen, reddened or sticky eyelids*

Please enter a number from 0 to 4.

Bags or dark circles under eyes*

Please enter a number from 0 to 4.

Blurred or tunnel vision (does not include near- or far-sightedness)*

Please enter a number from 0 to 4.

Total

Head

Headaches*

Please enter a number from 0 to 4.

Faintness*

Please enter a number from 0 to 4.

Dizziness*

Please enter a number from 0 to 4.

Insomnia*

Please enter a number from 0 to 4.

Total

Heart

Irregular or skipped heartbeat*

Please enter a number from 0 to 4.

Rapid or pounding heartbeat*

Please enter a number from 0 to 4.

Chest pain*

Please enter a number from 0 to 4.

Total

Joint/Muscles

Pain or aches in joints*

Please enter a number from 0 to 4.

Arthritis*

Please enter a number from 0 to 4.

Stiffness or limitation of movement*

Please enter a number from 0 to 4.

Pain or aches in muscles*

Please enter a number from 0 to 4.

Feeling of weakness or tiredness*

Please enter a number from 0 to 4.

Total

Lungs

Chest congestion*

Please enter a number from 0 to 4.

Asthma, bronchitis*

Please enter a number from 0 to 4.

Shortness of breath*

Please enter a number from 0 to 4.

Difficult breathing*

Please enter a number from 0 to 4.

Total

Mind

Poor memory*

Please enter a number from 0 to 4.

Confusion, poor comprehension*

Please enter a number from 0 to 4.

Poor concentration*

Please enter a number from 0 to 4.

Poor physical coordination*

Please enter a number from 0 to 4.

Difficulty in making decisions*

Please enter a number from 0 to 4.

Stuttering or stammering*

Please enter a number from 0 to 4.

Slurred speech*

Please enter a number from 0 to 4.

Learning disabilities*

Please enter a number from 0 to 4.

Total

Mouth/Throat

Chronic coughing*

Please enter a number from 0 to 4.

Gagging, frequent need to clear throat*

Please enter a number from 0 to 4.

Sore throat, hoarseness, loss of voice*

Please enter a number from 0 to 4.

Swollen/discolored tongue, gum, lips*

Please enter a number from 0 to 4.

Canker sores*

Please enter a number from 0 to 4.

Total

Nose

Stuffy nose*

Please enter a number from 0 to 4.

Sinus problems*

Please enter a number from 0 to 4.

Hay fever*

Please enter a number from 0 to 4.

Sneezing attacks*

Please enter a number from 0 to 4.

Excessive mucus formation*

Please enter a number from 0 to 4.

Total

Skin

Acne*

Please enter a number from 0 to 4.

Hives, rashes, or dry skin*

Please enter a number from 0 to 4.

Hair loss*

Please enter a number from 0 to 4.

Flushing or hot flushes*

Please enter a number from 0 to 4.

Excessive sweating*

Please enter a number from 0 to 4.

Total

Weight

Binge eating/drinking*

Please enter a number from 0 to 4.

Craving certain foods*

Please enter a number from 0 to 4.

Excessive weight*

Please enter a number from 0 to 4.

Compulsive eating*

Please enter a number from 0 to 4.

Water retention*

Please enter a number from 0 to 4.

Underweight*

Please enter a number from 0 to 4.

Total

Other

Frequent illness*

Please enter a number from 0 to 4.

Frequent or urgent urination*

Please enter a number from 0 to 4.

Genital itch or discharge*

Please enter a number from 0 to 4.

Total

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