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Multiple Symptom Questionnaire

Name
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
Faintness
Dizziness
Insomnia

Eyes

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)

Ears

Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss

Nose

Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

Mouth/Throat

Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

Skin

Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

Heart

Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Lungs

Asthma, bronchitis
Chest congestion
Shortness of breath
Difficulty breathing

Digestive Tract

Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

Joints/Muscles

Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Weight

Craving certain foods
Binge eating/drinking
Excessive weight
Compulsive eating
Underweight
Water retention

Energy/Activity

Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

Mind

Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities

Emotions

Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Other

Frequent illness
Frequent or urgent urination
Genital itch or discharge