Medical Symptoms Questionnaire (MSQ)

Medical Symptoms Questionnaire (MSQ) - 2
Name

First NameLast Name
Email
example@example.com
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
How would you describe your diet
How many Covid vaccinations have you had?
Do you take prescribed medications? If so, what are they and what condition are they for?
Do you take any supplements? If so, what are they and what condition are they for?
Do you have any other diagnosed conditions?
What is your history of illnesses? Any food poisoning? Any surgery?
Were you a vaginal birth? Were you breast fed?
What is your antibiotic history? Please state when and why you last took antibiotics?
Do you have any allergies or intolerances?
If you would like to lose weight, please write your current weight in KG here
and your desired weight in KG here

Head

Rows	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
Headaches
Faintness/Dizziness

Eyes

Rows	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
Watery or itchy
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes

Ears

Rows	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
Itchy
Earaches, ear infections
Ringing in ears, hearing loss

Nose

Rows	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
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

Mouth/Throat

Rows	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
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Canker sores

Heart

Rows	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
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Lungs

Rows	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
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Digestive Tract

Rows	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
Nausea, vomiting
Diarrhoea
Constipation
Bloated feeling
Belching, passing gas
Heartburn/acid reflux
Intestinal/stomach pain

Skin

Rows	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
Acnes
Hives, rashes, dry skin
Hair loss
Brittle, splitting, ridged nails
Flushing, hot flushes
Excessive sweating

Joints/Muscles

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

Weight

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

Mind

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

Emotions

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

Energy/Activity

Rows	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
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness/cramps
Feel the cold
Insomnia

Other

Rows	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
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Total
Grand Total/276
Note that less than 10 = optimal

More than 50 suggests the presence of significant inflammation and/or toxic load problems.

From Toolbox, Institute for Functional Medicine
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Medical Symptoms Questionnaire (MSQ) - 2