Medical Symptom Questionnaire

Name(Required)
MM slash DD slash YYYY

The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are completing this after your first time, then record your symptoms for the last 48 hours ONLY.

Point Scale

0 = I do not have this 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

Digestive Tract

Nausea or vomiting(Required)
Diarrhea(Required)
Constipation(Required)
Bloated feeling(Required)
Belching or passing gas(Required)
Heartburn(Required)
Intestinal/Stomach pain(Required)

Ears

Itchy Ears(Required)
Earaches, ear infections(Required)
Drainage from ear(Required)
Ringing in ears, hearing loss(Required)

Emotions

Mood swings(Required)
Anxiety, fear, or nervousness(Required)
Anger, irritability, or agressiveness(Required)
Depression(Required)

Energy/Activity

Fatigue, sluggishness(Required)
Apathy, lethargy(Required)
Hyperactivity(Required)
Restlessness(Required)

Eyes

Watery or itchy eyes(Required)
Swollen, reddened or sticky eyelids(Required)
Bags or dark circles under eyes(Required)
Blurred or tunnel vision (does not include near or far-sightedness)(Required)

Head

Headaches(Required)
Faintness(Required)
Dizziness(Required)
Insomnia(Required)

Heart

Irregular or skipped hearbeat(Required)
Rapid or pounding heartbeat(Required)
Chest pain(Required)

Joints/Muscles

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

Lungs

Chest congestion(Required)
Asthma, bronchitis(Required)
Shortness of breath(Required)
Difficult breathing(Required)

Mind

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

Mouth/Throat

Chronic coughing(Required)
Gagging, frequent need to clear throat(Required)
Sore throat, hoarseness, lose of voice(Required)
Sweollen/discolored tongue, gum, lips(Required)
Canker sores(Required)

Nose

Stuffy nose(Required)
Sinus problems(Required)
Hay fever(Required)
Sneezing attacks(Required)
Excessive mucus formation(Required)

Skin

Acne(Required)
Hives, rashes or dry skin(Required)
Flushing or hot flushes(Required)
Excessive sweating(Required)

Weight

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

Other

Frequent Illness(Required)
Frequent or urgent urination(Required)
Genital itch or discharge(Required)