MSQ – MEDICAL SYMPTOM / TOXICITY QUESTIONNAIRE

Please correct the errors described below.

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 for the past 30 days. If you are taking this for a repeat visit, record your symptoms for the past 48 hours ONLY.

Point scale:

0 = Never or almost never have these symptoms

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

EARS

EMOTIONS

ENERGY/ACTIVITY

EYES

(not near or farsightedness)

HEAD

HEART

JOINTS/MUSCLES

LUNGS

MIND

MOUTH/THROAT

NOSE

SKIN

WEIGHT

OTHER

GRAND TOTAL

KEY TO QUESTIONNAIRE

Add individual scores for each group. Add each group scores to get a grand total.

  • Optimal is less than 10
  • Mild Toxicity: 10-50
  • Moderate Toxicity: 50-100
  • Severe Toxicity: over 100

Your information will be encrypted.

Loading...