Medical Symptoms Questionnaire

Medical Symptoms Questionnaire

Patient Name______Date ______

Rate each of the following symptoms based upon your typical health profile for the Past 30 days

Point Scale0 - 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

HEAD ______Headaches

______Faintness

______Dizziness

______Insomnia

Total______

EYES

______Watery or Itchy Eyes

______Swollen, Reddened or Sticky Eyelids
______Bags or Dark Circles Under Eyes

______Blurred or Tunnel Vision

(does not include near or far-sighted)

Total______

EARS

______Itchy Ears

______Earaches, Ear Infections

______Drainage from Ear

______Ringing in Ears, Hearing Loss

Total______

NOSE

______Stuffy Nose

______Sinus Problems

______Hay Fever

______Sneezing Attacks

______Excessive Mucus Formation

Total______

MOUTH/THROAT

______Chronic Coughing

______Gagging, Frequent Need to Clear Throat

______Sore Throat, Hoarseness, Loss of Voice

______Swollen or Discolored Tongue, Gums, or Lips

______Canker Sores

Total______

SKIN

______Acne

______Hives, Rashes, Dry Skin

______Hair Loss

______Flushing, Hot Flashes

______Excessive Sweating

Total______

HEART

______Irregular or Skipped Heartbeat

______Rapid or Pounding Heartbeat

______Chest Pain

Total______

LUNGS

______Chest Congestion

______Asthma, Bronchitis

______Shortness of Breath

______Difficulty Breathing

Total______

DIGESTIVETRACT

______Nausea, Vomiting

______Diarrhea

______Constipation

______Bloated Feeling

______Belching, Passing Gas

______Heartburn

______Intestinal/Stomach Pain

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______

WEIGHT

______Binge Eating/Drinking

______Craving Certain Foods

______Excessive Weight

______Compulsive Eating

______Water Retention

______Underweight

Total______

ENERGY/ACTIVITY

______Fatigue, Sluggishness

______Apathy, Lethargy

______Hyperactivity

______Restlessness

Total______

MIND

______Poor Memory

______Confusion, Poor Comprehension

______Poor Concentration

______Poor Physical Condition

______Difficulty in Making Decisions

______Stuttering or Stammering

______Slurred Speech

______Learning Disabilities

Total______

EMOTIONS

______Mood Swings

______Anxiety, Fear, Nervousness

______Anger, Irritability, Aggressiveness

______Depression

Total______

OTHER

______Frequent Illness

______Frequent or Urgent Urination

______Genital Itch or Discharge

Total______

GRAND TOTAL ______

Activities of Daily Living Report

Please Specify the Effect of your Current Condition on the following Daily Activities:

Bending: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Caring for Infirm Family: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Changing Positions:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Climbing Stairs: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Daily Pet Care: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Driving: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Ext Computer Use: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Household Chores:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Kneeling: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Lifting: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Reading/Concentration: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Self Care–Bathing:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Self Care–Dressing: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Self Care–Shaving:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Sexual Activities:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Sleep: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Static Sitting: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Static Standing: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Walking: No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Yard Work:  No Effect  Mild Painful (Can do)  Mod Painful (Limited)  Sev Unable to Perform

Please Specify any OTHER Recreational Activity affected by your Current Condition. How is it Affected?

______ No Effect  Mild Painful (Can do)  Mod Painful (limited)  Sev Unable to Perform