Medical Symptoms Questionnaire

Please use the below scores to rank your symptoms. Page 1: Head

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Headache

Selected Value: 0

Dizziness

Selected Value: 0

Faintness

Selected Value: 0

Insomnia

Selected Value: 0

Page 2: Eyes

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Watery, itchy

Selected Value: 0

Swollen, red, sticky eyelids

Selected Value: 0

Bags or dark circles

Selected Value: 0

Blurred or tunnel vision

Selected Value: 0

Page 3: Ears

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Itchy

Selected Value: 0

Earaches, infections

Selected Value: 0

Drainage

Selected Value: 0

Ringing, hearing loss

Selected Value: 0

Page 4: Nose

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Stuffy nose

Selected Value: 0

Sinus Problems

Selected Value: 0

Hay fever

Selected Value: 0

Sneezing attacks

Selected Value: 0

Excessive mucus

Selected Value: 0

Page 5: Heart

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Irregular of skipped beat

Selected Value: 0

Rapid, pounding beat

Selected Value: 0

Chest pain

Selected Value: 0

Page 6: Mouth/Throat

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Chronic coughing

Selected Value: 0

Gagging/clearing throat

Selected Value: 0

Sore throat, voice loss

Selected Value: 0

Swollen, discolored tongue, gums or lip

Selected Value: 0

Canker sore

Selected Value: 0

Page 7: Skin

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Acne

Selected Value: 0

Hives, rash, dry skin

Selected Value: 0

Hair loss

Selected Value: 0

Flushing, hot flashing

Selected Value: 0

Excessive sweating

Selected Value: 0

Page 7: Lungs

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Chest congestion

Selected Value: 0

Asthma, bronchitis

Selected Value: 0

Shortness of breath

Selected Value: 0

Difficulty breathing

Selected Value: 0

Page 8: Digestive Tract

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Nausea, vomiting

Selected Value: 0

Diarrhea

Selected Value: 0

Constipation

Selected Value: 0

Bloated feeling

Selected Value: 0

Belching, gas

Selected Value: 0

Heartburn

Selected Value: 0

Intestinal/stomach pain

Selected Value: 0

Page 9: Joints/Muscle

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Pain or aches in joints

Selected Value: 0

Arthritis

Selected Value: 0

Stiffness, limited movement

Selected Value: 0

Muscle pain/ache

Selected Value: 0

Weakness/tired

Selected Value: 0

Page 10: Energy/Activity

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Fatigue

Selected Value: 0

Apathy, lethargy

Selected Value: 0

Hyperactivity

Selected Value: 0

Restlessness

Selected Value: 0

Page 11: Weight

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Binge eating/drinking

Selected Value: 0

Craving

Selected Value: 0

Excessive weight

Selected Value: 0

Compulsive eating

Selected Value: 0

Water retention

Selected Value: 0

Underweight

Selected Value: 0

Page 12: Mind

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Poor memory

Selected Value: 0

Confusion, poor comprehension

Selected Value: 0

Poor concentration

Selected Value: 0

Poor coordination

Selected Value: 0

Difficulty making decision

Selected Value: 0

Stuttering, stammering

Selected Value: 0

Slurred speech

Selected Value: 0

Learning disabled

Selected Value: 0

Page 13: Emotion

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Mood swings

Selected Value: 0

Anxiety, fear nervousness

Selected Value: 0

Anger, irritability

Selected Value: 0

Depression

Selected Value: 0

Page 14: Other

0 = Never or almost never. 1 = Occasionally, not severe. 2 = Occasionally, severe. 3 = Frequently, not severe. 4 = Frequently, severe.

Frequent Illness

Selected Value: 0

Frequent/urgent urination

Selected Value: 0

Genital itch/ discharge

Selected Value: 0

Your Results

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Media

Please use the below scores to rank your symptoms. Page 1: Head

Page 2: Eyes

Page 3: Ears

Page 4: Nose

Page 5: Heart

Page 6: Mouth/Throat

Page 7: Skin

Page 7: Lungs

Page 8: Digestive Tract

Page 9: Joints/Muscle

Page 10: Energy/Activity

Page 11: Weight

Page 12: Mind

Page 13: Emotion

Page 14: Other

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In the Media

Please use the below scores to rank your symptoms. Page 1: Head

Page 2: Eyes

Page 3: Ears

Page 4: Nose

Page 5: Heart

Page 6: Mouth/Throat

Page 7: Skin

Page 7: Lungs

Page 8: Digestive Tract

Page 9: Joints/Muscle

Page 10: Energy/Activity

Page 11: Weight

Page 12: Mind

Page 13: Emotion

Page 14: Other

Your Results