Medical Symptom Questionnaire
ICCLI uses Medical Symptom Questionnaire (MSQ) developed by the Institute for Functional Medicine (IFM).
THIS QUESTIONNAIRE IS FOR INFORMATIONAL PURPOSES ONLY. IT DOES NOT PROVIDE DIAGNOSIS, TREATMENT OR MEDICAL ADVICE.
Rate each of the following symptoms based upon your typical health profile for the past 14 days.

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

First Name
Your answer
Gender
Age
type in numbers only, 18-100
Your answer
Email address
please, provide an email address to receive your score
Your answer
HEAD
Maximal score: 16
HEADACHE
Never or almost never
Frequently have it, effect is severe
FAINTNESS
Never or almost never
Frequently have it, effect is severe
DIZZINESS
Never or almost never
Frequently have it, effect is severe
INSOMNIA
Never or almost never
Frequently have it, effect is severe
EYES
Maximal score: 16
WATERY OR ITCHY EYES
Never or almost never
Frequently have it, effect is severe
SWOLLEN, RED OR STICKY EYELIDS
Never or almost never
Frequently have it, effect is severe
BAGS OR DARK CIRCLES UNDER EYES
Never or almost never
Frequently have it, effect is severe
BLURRED OR TUNNEL VISION
excludes far or near-sighthedness
Never or almost never
Frequently have it, effect is severe
EARS
Maximal score: 16
ITCHY EARS
Never or almost never
Frequently have it, effect is severe
EARACHES, EAR INFECTIONS
Never or almost never
Frequently have it, effect is severe
DRAINAGE FROM EAR
Never or almost never
Frequently have it, effect is severe
RINGING IN EARS, HEARING LOSS
Never or almost never
Frequently have it, effect is severe
NOSE
Maximal score: 20
STUFFY NOSE
Never or almost never
Frequently have it, effect is severe
SINUS PROBLEMS
Never or almost never
Frequently have it, effect is severe
HAY FEVER
Never or almost never
Frequently have it, effect is severe
SNEEZING ATTACKS
Never or almost never
Frequently have it, effect is severe
EXCESSIVE MUCUS FORMATION
Never or almost never
Frequently have it, effect is severe
MOUTH/THROAT
Maximal score: 20
CHRONIC COUGHING
Never or almost never
Frequently have it, effect is severe
GAGGING, FREQUENT NEED TO CLEAR THROAT
Never or almost never
Frequently have it, effect is severe
SORE THROAT, HOARSENESS, LOSS OF VOICE
Never or almost never
Frequently have it, effect is severe
SWOLLEN OR DISCOLORED TONGUE, GUMS, LIPS
Never or almost never
Frequently have it, effect is severe
CANKER SORES
Never or almost never
Frequently have it, effect is severe
SKIN
Maximal score: 20
ACNE
Never or almost never
Frequently have it, effect is severe
HIVES, RASHES, DRY SKIN
Never or almost never
Frequently have it, effect is severe
HAIR LOSS
Never or almost never
Frequently have it, effect is severe
FLUSHING, HOT FLASHES
Never or almost never
Frequently have it, effect is severe
EXCESSIVE SWEATING
Never or almost never
Frequently have it, effect is severe
HEART
Maximal score: 12
IRREGULAR OR SKIPPED HEART BEATS
Never or almost never
Frequently have it, effect is severe
RAPID OR POUNDING HEARTBEAT
Never or almost never
Frequently have it, effect is severe
CHEST PAIN
Never or almost never
Frequently have it, effect is severe
LUNGS
Maximal score: 16
CHEST CONGESTION
Never or almost never
Frequently have it, effect is severe
ASTHMA. BRONCHITIS
Never or almost never
Frequently have it, effect is severe
SHORTNESS OF BREATH
Never or almost never
Frequently have it, effect is severe
DIFFICULTY BREATHING
Never or almost never
Frequently have it, effect is severe
DIGESTIVE TRACT
Maximal score: 28
NAUSEA, VOMITING
Never or almost never
Frequently have it, effect is severe
DIARRHEA
Never or almost never
Frequently have it, effect is severe
CONSTIPATION
Never or almost never
Frequently have it, effect is severe
BLOATED FEELING
Never or almost never
Frequently have it, effect is severe
BELCHING, PASSING GAS
Never or almost never
Frequently have it, effect is severe
HEARTBURN
Never or almost never
Frequently have it, effect is severe
INTESTINAL/STOMACH PAIN
Never or almost never
Frequently have it, effect is severe
JOINTS/MUSCLE
Maximal score: 20
PAIN OR ACHES IN JOINTS
Never or almost never
Frequently have it, effect is severe
ARTHRITIS
Never or almost never
Frequently have it, effect is severe
STIFFNESS OR LIMITATION OF MOVEMENT
Never or almost never
Frequently have it, effect is severe
PAIN OR ACHES IN MUSCLES
Never or almost never
Frequently have it, effect is severe
FEELINGS OF WEAKNESS OR TIREDNESS
Never or almost never
Frequently have it, effect is severe
WEIGHT
Maximal score: 24
BINGE EATING/DRINKING
Never or almost never
Frequently have it, effect is severe
CRAVING CERTAIN FOODS
Never or almost never
Frequently have it, effect is severe
EXCESSIVE WEIGHT
Never or almost never
Frequently have it, effect is severe
COMPULSIVE EATING
Never or almost never
Frequently have it, effect is severe
WATER RETENTION
Never or almost never
Frequently have it, effect is severe
UNDERWEIGHT
Never or almost never
Frequently have it, effect is severe
ENERGY/ACTIVITY
Maximal score: 20
FATIGUE, SLUGGISHNESS
Never or almost never
Frequently have it, effect is severe
APATHY, LETHARGY
Never or almost never
Frequently have it, effect is severe
HYPERACTIVITY
Never or almost never
Frequently have it, effect is severe
RESTLESSNESS
Never or almost never
Frequently have it, effect is severe
MIND
Maximal score: 32
POOR MEMORY
Never or almost never
Frequently have it, effect is severe
CONFUSION, POOR COMPREHENSION
Never or almost never
Frequently have it, effect is severe
POOR CONCENTRATION
Never or almost never
Frequently have it, effect is severe
POOR PHYSICAL COORDINATION
Never or almost never
Frequently have it, effect is severe
DIFFICULTY MAKING DECISIONS
Never or almost never
Frequently have it, effect is severe
STUTTERING OR STAMMERING
Never or almost never
Frequently have it, effect is severe
SLURRED SPEECH
Never or almost never
Frequently have it, effect is severe
LEARNING DISABILITIES
Never or almost never
Frequently have it, effect is severe
EMOTIONS
Maximal score: 20
MOOD SWINGS
Never or almost never
Frequently have it, effect is severe
ANXIETY, FEAR, NERVOUSNESS
Never or almost never
Frequently have it, effect is severe
ANGER, IRRITABILITY, AGGRESSIVENESS
Never or almost never
Frequently have it, effect is severe
DEPRESSION
Never or almost never
Frequently have it, effect is severe
OTHER
Maximal score: 12
FREQUENT ILLNESS
Never or almost never
Frequently have it, effect is severe
FREQUENT OR URGENT URINATION
Never or almost never
Frequently have it, effect is severe
GENITAL ITCH OR DISCHARGE
Never or almost never
Frequently have it, effect is severe
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