Rate each of the following symptoms based on your typical health profile over the past 14 days. Note: Your final score will be tallied after submission

Point Scale
0 = Never or almost never have the symptom
1 = Occasionally have it, the effect is not severe
2 = Occasionally have, the effect is severe
3 = Frequently have it, the effect is not severe
4 = Frequently have it, the effect is severe

Medical Symptoms Questionnaire

  • Medical Symptoms Questionnaire

    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.
  • Head

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Eyes

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
    (does not include near-or far-sightedness)
  • Ears

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Nose

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Mouth / Throat

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Skin

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Heart

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Lungs

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Digestive Tract

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Joint / Muscle

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Weight

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Energy / Activity

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Mind

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Emotions

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Other

    Rate each of the following symptoms based upon your typical health profile for the past 14 days.
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe
  • Never or rarely have the symptomOccasionally have it, effect is not severeOccasionally have it, effect is severeFrequently have it, effect is not severeFrequently have it, effect is severe