Medical Symptoms Questionnaire

Name

First NameLast Name

Date

Please rate your symptoms based on how you feel in the last 30 days or 48 hrs

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

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-sightedness)

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, Hearing loss

Stuffy Nose

Sinus problems / Excessive mucus formation

Hay Fever

Sneezing attack

Chronic Coughing

Gagging

Sore throat, hoarseness, loss of voice

Swollen or discolored tongue, gums, lips, canker sores

Acne

Hives, rashes, dry skin

Hair loss

Flushing, hot flashes

Excessive sweating

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest Pain

Chest congestion

Asthma

Shortness of breathe

Difficulty Breathing

Nausea, vomiting

Diarrhea

Constipation

Bloating feeling

Belching, passing gas

Heartburn

Intestinal/Stomach pain

Medical Symptoms Questionnaire

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

Eyes

Ears

Nose

Mouth/Throat

Skin

Heart

Lungs

Digestive Tract