Medical Symptoms Questionnaire

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

Rate each of the following symptoms based upon your typical health profile for the past 30 days OR since your last visit.

HEAD

Headaches

Faintness

Dizziness

Insomnia

Total

HEART

Irregular/Skipped heartbeat

Rapid or pounding heartbeat

Chest Pain

Total

MIND

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty making decisions

Stuttering or Stammering

Slurred speech

Learning disabilities

Total

EYES

Water or itchy eyes

Swollen, reddened, or sticky eyelids

Bags/Dark circles under eyes

Blurred/Tunnel vision

Total

LUNGS

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Total

EMOTIONS

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression

Total

EARS

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Total

DIGESTIVE TRACT

Nausea, vomiting

Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain

Total

SKIN

Acne

Hives, rashes, dry skin

Hair loss

Flushing, hot flashes

Excessive sweating

Total

NOSE

Stuffy nose

Sinus problems

Hay Fever

Sneezing attacks

Excessive mucus formation

Total

JOINTS/MUSCLE

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

Total

ENERGY/ACTIVITY

Fatigue, sluggishness

Apathy, lethargy

Hyperactivity

Restlessness

Total

MOUTH/THROAT

Chronic coughing

Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen/discolored tongue, gums or lips

Canker sores

Total

WEIGHT

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

Total

OTHER

Frequent illness

Frequent, urgent, difficult, or painful urination

Genital itch or discharge

Total

GRAND TOTAL

Are you moving your body?

Y N

STRESS: Are you stressed in any of these areas? Please check.

physical

emotional

intellectual

spiritual

What supplement/medications do you take? How often and what dose?

NB: On a scale of 1-10 (10 means optimal), where do you self rate your overall health for the past 30 days? /

REASON FOR TODAY’S APPOINTMENT

Name

Age

Date

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