MSQ FORM
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ABCDEFGHIJKLMNOPQRSTUVWXYZ
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NAME:
MULTIPLE SYMPTOM
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DOB:QUESTIONNAIRE
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ADDRESS:
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EMAIL:
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DATE:
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0 = Never or almost never have the symptom
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1 = Occasionally have it, effect is not severe
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2 = Occasionally have, effect is severe
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3 = Frequently have it, effect is not severe
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4 = Frequently have it, effect is severe
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DIGESTIVE TRACT HEAD MOUTH/THROAT
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Nausea or vomiting 0Headaches 0Chronic Cough0
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Diarrhea 0Faintness 0
Gagging, frequent need to clear throat
0
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Constipation 0Dizziness 0
Sore Throat, hoarseness, loss of voice
0
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Bloated feeling 0Insomnia 0
Swollen/discolored tongue, gums, lips
0
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Belching, or passing gas 0TOTAL HEAD0Canker Sores0
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Heartburn 0HEARTTOTAL MOUTH/THROAT0
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Intestinal/Stomach pain 0
Irregular or skipped heartbeat
0NOSE
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TOTAL GI0
Rapid or pounding heartbeat
0Stuffy nose0
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EARS Chest pain 0Sinus problems0
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Itchy ears0TOTAL HEART0Hay fever0
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Earaches, ear infections 0JOINTS/MUSCLESSneezing attacks0
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Drainage from ear 0Pain or aches in Joints0Excessive mucous production0
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Ringing in ears, hearing loss
0Arthritis0TOTAL NOSE0
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TOTAL EARS0
Stiffness or limitation of movement
0SKIN
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EMOTIONS Pain or aches in muscles0Acne0
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Mood swings 0
TOTAL JOINTS/MUSCLES
0Hives, rash, dry skin0
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Anxiety, fear or nervousness
0LUNGSHair loss0
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Anger, irritability, or aggressiveness
0Chest congestion0Flushing or hot flashes0
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Depression 0Asthma, bronchitis0Excessive sweating0
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TOTAL EMOTIONS0Shortness of breath0TOTAL SKIN0
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ENERGY/ACTIVITY Difficulty breathing0WEIGHT
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Fatigue, sluggishness 0TOTAL LUNGS0Binge eating/drinking0
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Apathy, lethargy 0MINDCraving certain foods0
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Hyperactivity 0Poor Memory0Excessive weight0
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Restlessness 0
Confusion, poor comprehension
0Compulsive eating0
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TOTAL ENERGY0
Poor physical coordination
0Water retention0
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EYESDifficulty making decisions0Underweight, weight loss0
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Watery or itchy eyes 0
Stuttering or stammering
0TOTAL WEIGHT
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Swollen, reddened or sticky eyelids
0Slurred speech0OTHER
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Bags or dark circles under eyes
0Learning disabilities0Frequent illness0
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Blurred or tunnel vision (does not
0TOTAL MIND0Frequent or urgent urination0
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include near-or far-sightedness)
Genital itch or discharge0
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TOTAL EYES0TOTAL OTHER0
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GRAND TOTAL0
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Optimal is less than 10 Mild Toxicity: 10-50 Moderate Toxicity: 50-100 Severe Toxicity: over 100
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66
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100
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