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

Name*
First Last
Email*
Phone*
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.
Headaches*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Faintness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Dizziness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Insonia*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Eyes
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Watery or itchy eyes*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Swollen, reddened or sticky eyelids*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Bags or dark circles under eyes*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Blurred or tunnel vision (does not include near-or far-sightedness)*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently 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.
Itchy Ears*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Earaches, ear infections*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Drainage from ear*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Ringing in ears, hearing loss*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Nose
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Stuffy nose*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Sinus problems*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Hay fever*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Sneezing attacks*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Excessive mucus formation*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Mouth / Throat
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Chronic coughing*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Gagging, frequent need to clear throat*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Sore throat, hoarseness, loss of voice*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Swollen/discolored tongue, gum, lips*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Canker sores*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Skin
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Acne*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Hives, rashes, or dry skin*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Hair loss*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Excessive sweating*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Flushing or hot flushes*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Heart
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Irregular or skipped heartbeat*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Rapid or pounding heartbeat*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Chest Pain*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Lungs
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Chest congestion*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Asthma, bronchitis*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Shortness of breath*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Difficult breathing*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Digestive Tract
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Nausea or vomiting*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Diarrhea*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Constipation*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Bloated feeling*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Belching, or passing gas*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Heartburn*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Intestinal/Stomach pain*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Joint / Muscle
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Pain or aches in joints*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Arthritis*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Stiffness or limitation of movement*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Pain or aches in muscles*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Feeling of weakness or tiredness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Weight
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Binge eating/drinking*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Craving certain foods*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Excessive weight*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Compulsive eating*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Water retention*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Underweight*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Energy / Activity
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Fatigue, sluggishness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Apathy, lethargy*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Hyperactivity*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Restlessness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Mind
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Poor memory*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Confusion, poor comprehension*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Poor concentration*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Poor physical coordination*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Difficulty in making decisions*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Stuttering or stammering*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Slurred speech*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Learning disabilities*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Emotions
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Mood swings*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Anxiety, fear or nervousness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Anger, irritability, or aggressiveness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Depression*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Other
Rate each of the following symptoms based upon your typical health profile for the past 14 days.
Frequent illness*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Frequent or urgent urination*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe
Genital itch or discharge*
Never or rarely have the symptom Occasionally have it, effect is not severe Occasionally have it, effect is severe Frequently have it, effect is not severe Frequently have it, effect is severe

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

Medical Symptoms Questionnaire

Medical Symptoms Questionnaire

Head

Eyes

Ears

Nose

Mouth / Throat

Skin

Heart

Lungs

Digestive Tract

Joint / Muscle

Weight

Energy / Activity

Mind

Emotions

Other

Sayana Medical and Wellness Center

Follow Us

What We Do

Clinic Address

Newsletter