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Wish to talk directly with our provider?
Book a free discovery call today!

Opening September 2023 to Accept New Clients

Get on Our Waitlist to Receive Updates First

Name(Required)

First Last

Email(Required)

Δ

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Functional Medicine
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Resources
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Contact
Patient Portal

Multiple Symptom Questionnaire

Name

First Last

Email

Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Point 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

Head

Headaches

0

1

2

3

4

Faintness

0

1

2

3

4

Dizziness

0

1

2

3

4

Insomnia

0

1

2

3

4

Eyes

Watery or itchy eyes

0

1

2

3

4

Swollen, reddened or sticky eyelids

0

1

2

3

4

Bags or dark circles under eyes

0

1

2

3

4

Blurred or tunnel vision

0

1

2

3

4

(does not include near or far-sightedness)

Ears

Itchy ears

0

1

2

3

4

Earaches, ear infections

0

1

2

3

4

Drainage from ear

0

1

2

3

4

Ringing in ears, hearing loss

0

1

2

3

4

Nose

Stuffy nose

0

1

2

3

4

Sinus problems

0

1

2

3

4

Hay fever

0

1

2

3

4

Sneezing attacks

0

1

2

3

4

Excessive mucus formation

0

1

2

3

4

Mouth/Throat

Chronic coughing

0

1

2

3

4

Gagging, frequent need to clear throat

0

1

2

3

4

Sore throat, hoarseness, loss of voice

0

1

2

3

4

Swollen or discolored tongue, gums, lips

0

1

2

3

4

Canker sores

0

1

2

3

4

Skin

Acne

0

1

2

3

4

Hives, rashes, dry skin

0

1

2

3

4

Hair loss

0

1

2

3

4

Flushing, hot flashes

0

1

2

3

4

Excessive sweating

0

1

2

3

4

Heart

Irregular or skipped heartbeat

0

1

2

3

4

Rapid or pounding heartbeat

0

1

2

3

4

Chest pain

0

1

2

3

4

Lungs

Asthma, bronchitis

0

1

2

3

4

Chest congestion

0

1

2

3

4

Shortness of breath

0

1

2

3

4

Difficulty breathing

0

1

2

3

4

Digestive Tract

Nausea, vomiting

0

1

2

3

4

Diarrhea

0

1

2

3

4

Constipation

0

1

2

3

4

Bloated feeling

0

1

2

3

4

Belching, passing gas

0

1

2

3

4

Heartburn

0

1

2

3

4

Intestinal/stomach pain

0

1

2

3

4

Joints/Muscles

Pain or aches in joints

0

1

2

3

4

Arthritis

0

1

2

3

4

Stiffness or limitation of movement

0

1

2

3

4

Pain or aches in muscles

0

1

2

3

4

Feeling of weakness or tiredness

0

1

2

3

4

Weight

Craving certain foods

0

1

2

3

4

Binge eating/drinking

0

1

2

3

4

Excessive weight

0

1

2

3

4

Compulsive eating

0

1

2

3

4

Underweight

0

1

2

3

4

Water retention

0

1

2

3

4

Energy/Activity

Fatigue, sluggishness

0

1

2

3

4

Apathy, lethargy

0

1

2

3

4

Hyperactivity

0

1

2

3

4

Restlessness

0

1

2

3

4

Mind

Poor memory

0

1

2

3

4

Confusion, poor comprehension

0

1

2

3

4

Poor concentration

0

1

2

3

4

Poor physical coordination

0

1

2

3

4

Difficulty in making decisions

0

1

2

3

4

Stuttering or stammering

0

1

2

3

4

Slurred speech

0

1

2

3

4

Learning disabilities

0

1

2

3

4

Emotions

Mood swings

0

1

2

3

4

Anxiety, fear, nervousness

0

1

2

3

4

Anger, irritability, aggressiveness

0

1

2

3

4

Depression

0

1

2

3

4

Other

Frequent illness

0

1

2

3

4

Frequent or urgent urination

0

1

2

3

4

Genital itch or discharge

0

1

2

3

4

Δ

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