Metabolic Screening Questionnaire (MSQ)

Metabolic Screening Questionnaire (MSQ)

To evaluate progress in health and wellness consultations. Create a HIPAA Compliant Metabolic Screening Questionnaire (MSQ) today. Form Preview
  • Metabolic Screening Questionnaire (MSQ)

  •  -  - Pick a Date
  • Please rate the following symptoms based on your health for the past 30 days.

    Point Scale:

    0 = Never or almost never have the symptom.

    1 = Occasionally have the symptom; effect is not severe.

    2 = Occasionally have the symptom; effect is severe.

    3 = Frequently have the symptom; effect is not severe.

    4 = Frequently have the symptom; effect is severe.

  •   Effect
    Nausea or vomiting
    Bloated feeling
    Belching or passing gas
  •   Effect
    Poor memory
    Confusion, poor comprehension
    Poor concentration
    Difficulty making decisions
    Stuttering or stammering
    Learning disabilities
  •   Effect
    Chronic coughing
    Gagging, frequent need to clear throat
    Sore throat, hoarseness, loss of voice
    Swollen or discolored tongue, gums, lips
    Canker sores
    Slurred speech
  •   Effect
    Sinus problems
    Hay fever
    Sneezing attacks
    Excessive mucus formation
  •   Effect
    Watery or itchy
    Swollen, red, sticky eyelids
    Bags, dark circles underneath
    Blurred or tunnel vision
  •   Effect
    Fatigue, sluggishness
    Apathy, lethargy
  •   Effect
    Irregular or skipped heartbeat
    Rapid or pounding heartbeat
    Chest pain
  •   Effect
    Itchy ears
    Earaches, ear infections
    Drainage from ear
    Ringing in ears, hearing loss
  •   Effect
    Hives, rashes or dry skin
    Hair loss
    Flushing or hot flashes
    Excessive sweating
  •   Effect
    Pain or aches in joints
    Stiffness or movement limitation
    Pain or aches in muscles
    Feeling of weakness or tiredness
  •   Effect
  •   Effect
    Binge eating/drinking
    Craving certain foods
    Excessive weight
    Compulsive eating
    Water retention
  •   Effect
    Chest congestion
    Asthma, bronchitis
    Shortness of breath
  •   Effect
    Mood swings
    Anxiety, fear or nervousness
    Anger, irritability or aggressiveness
  •   Effect
    Frequent illness
    Frequent or urgent urination
    Genital itch or discharge
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