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Name *

Date *

Rate each of the following symptoms based on your typical health profile for the past MONTH: Point Scale: 0 = Never or almost never have the symptom, 1 = Occasionally have it, 2 = Frequently have it

HEAD *Headaches0 - never or almost never1 - ocassionally2 - frequently

EYES *Watery or itchy eyes0 - never or almost never1 - ocassionally2 - frequently

Swollen, reddened or sticky eyelids0 - never or almost never1 - ocassionally2 - frequently

Blurred or tunnel vision0 - never or almost never1 - ocassionally2 - frequently

EARS *Itchy ears0 - never or almost never1 - ocassionally2 - frequently

Ear-aches, ear infections0 - never or almost never1 - ocassionally2 - frequently

Drainage from ear0 - never or almost never1 - ocassionally2 - frequently

Ringing in ears, hearing loss0 - never or almost never1 - ocassionally2 - frequently

NOSE *Stuffy nose0 - never or almost never1 - ocassionally2 - frequently

Sinus problems0 - never or almost never1 - ocassionally2 - frequently

Hay fever0 - never or almost never1 - ocassionally2 - frequently

Sneezing attacks0 - never or almost never1 - ocassionally2 - frequently

Excessive mucus formation0 - never or almost never1 - ocassionally2 - frequently

MOUTH / THROAT *Chronic coughing0 - never or almost never1 - ocassionally2 - frequently

Gagging, frequent need to clear throat0 - never or almost never1 - ocassionally2 - frequently

Sore throat, hoarseness, loss of voice0 - never or almost never1 - ocassionally2 - frequently

Swollen or discolored tongue, gums, lips0 - never or almost never1 - ocassionally2 - frequently

Canker sores0 - never or almost never1 - ocassionally2 - frequently

SKIN *Acne0 - never or almost never1 - ocassionally2 - frequently

Hives, rashes, dry skin0 - never or almost never1 - ocassionally2 - frequently

Hair loss0 - never or almost never1 - ocassionally2 - frequently

Flushing, hot flashes0 - never or almost never1 - ocassionally2 - frequently

Excessive sweating0 - never or almost never1 - ocassionally2 - frequently

HEART *Irregular or skipped heartbeat0 - never or almost never1 - ocassionally2 - frequently

Rapid or pounding heartbeat0 - never or almost never1 - ocassionally2 - frequently

Chest pain0 - never or almost never1 - ocassionally2 - frequently

LUNGS *Chest congestion0 - never or almost never1 - ocassionally2 - frequently

Asthma, bronchitis0 - never or almost never1 - ocassionally2 - frequently

Shortness of breath0 - never or almost never1 - ocassionally2 - frequently

Difficulty breathing0 - never or almost never1 - ocassionally2 - frequently

DIGESTIVE TRACT *Nausea, vomiting0 - never or almost never1 - ocassionally2 - frequently

Diarrhoea0 - never or almost never1 - ocassionally2 - frequently

Constipation0 - never or almost never1 - ocassionally2 - frequently

Bloated feeling0 - never or almost never1 - ocassionally2 - frequently

Belching, passing gas0 - never or almost never1 - ocassionally2 - frequently

Heartburn0 - never or almost never1 - ocassionally2 - frequently

Intestinal/stomach pain0 - never or almost never1 - ocassionally2 - frequently

JOINTS / MUSCLES *Pain or aches in joints0 - never or almost never1 - ocassionally2 - frequently

Arthritis0 - never or almost never1 - ocassionally2 - frequently

Stiffness or limitation of movement0 - never or almost never1 - ocassionally2 - frequently

Pain or aches in muscles0 - never or almost never1 - ocassionally2 - frequently

Feeling of weakness or tiredness0 - never or almost never1 - ocassionally2 - frequently

WEIGHT *Binge eating/drinking0 - never or almost never1 - ocassionally2 - frequently

Craving certain foods0 - never or almost never1 - ocassionally2 - frequently

Excessive weight0 - never or almost never1 - ocassionally2 - frequently

Compulsive eating0 - never or almost never1 - ocassionally2 - frequently

Water retention0 - never or almost never1 - ocassionally2 - frequently

Underweight0 - never or almost never1 - ocassionally2 - frequently

ENERGY / ACTIVITY *Fatigue, sluggishness0 - never or almost never1 - ocassionally2 - frequently

Apathy, lethargy0 - never or almost never1 - ocassionally2 - frequently

Hyperactivity0 - never or almost never1 - ocassionally2 - frequently

Restlessness0 - never or almost never1 - ocassionally2 - frequently

MIND *Poor memory0 - never or almost never1 - ocassionally2 - frequently

Confusion, poor comprehension0 - never or almost never1 - ocassionally2 - frequently

Poor concentration0 - never or almost never1 - ocassionally2 - frequently

Poor physical coordination0 - never or almost never1 - ocassionally2 - frequently

Difficulty in making decisions0 - never or almost never1 - ocassionally2 - frequently

Stuttering or stammering0 - never or almost never1 - ocassionally2 - frequently

Slurred speech0 - never or almost never1 - ocassionally2 - frequently

Learning disabilities0 - never or almost never1 - ocassionally2 - frequently

EMOTIONS *Mood swings0 - never or almost never1 - ocassionally2 - frequently

Anxiety, fear, nervousness0 - never or almost never1 - ocassionally2 - frequently

Anger, irritability, aggressiveness0 - never or almost never1 - ocassionally2 - frequently

Depression0 - never or almost never1 - ocassionally2 - frequently

OTHER *Frequent illness0 - never or almost never1 - ocassionally2 - frequently

Frequent or urgent urination0 - never or almost never1 - ocassionally2 - frequently

Genital itch or discharge0 - never or almost never1 - ocassionally2 - frequently

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Medical Symptom Questionnaire (MSQ)