Medical Symptoms Questionnaire
Name _____________________________
Date _________________
This Toxicity and Symptom Screening Questionnaire identifies symptoms that help to
identify underlying causes of illness and helps us track your progress. Rate each of the
following symptoms based upon your typical health profile for the past 30 days.
Point Scale
0
1
2
3
4
HEAD
________
________
________
________
Headaches
Faintness
Dizziness
Insomnia
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-sightedness) Total ________
EARS
________
________
________
________
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total ________
________
________
________
________
________
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total ________
________
________
________
________
________
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total ________
________
________
________
________
________
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Total ________
________
________
________
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain
Total ________
NOSE
MOUTH/THROAT
SKIN
HEART
-
Never or almost never have the symptom
Occasionally have it, effect is not severe
Occasionally have it, effect is severe
Frequently have it, effect is not severe
Frequently have it, effect is severe
Applying Functional Medicine in Clinical Practice
Total ________
Medical Symptoms Questionnaire
LUNGS
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total ________
DIGESTIVE TRACT ________
________
________
________
________
________
________
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 ________
________
________
________
________
________
________
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 coordination
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Total ________
________
________
________
________
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total ________
________
________
________
Frequent illness
Frequent or urgent urination
Genital itch or discharge
WEIGHT
EMOTIONS
OTHER
________
________
________
________
Total ________
GRAND TOTAL
TOTAL _________
Add individual scores and total each group. Add each group scores for a grand total.
Optimal: < 10 Mild toxicity: 10-50 Moderate toxicity: 50-100 Severe toxicity: > 100
Applying Functional Medicine in Clinical Practice