Multi Sympton Questionnaire

Rate each of the following symptoms according to your recent health status.

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


EARS

Itchy Ears	_____

Earache or Ear Infections	_____

Hearing loss or blocked ears	_____

Ringing or buzzing in ears	_____
	TOTAL
	______


EYES

Watery or itchy eyes	_____

Swollen, reddened or sticky eyelids	_____

Bags or dark circles under eyes	_____

Blurred or tunnel vision or visual disturbance	_____
(does not include near or far-sightedness)
	TOTAL
	______


NOSE

Stuffy nose or Nasal discharge	_____

Sinus congestion or Sinus infection	_____

Hay fever or Sneezing attacks	_____

Postnasal drip or Excessive mucus production	_____
	TOTAL
	______


MOUTH / THROAT

Chronic coughing or clearing of throat	_____

Frequent gagging or difficulty swallowing	_____

Sore throat, hoarseness, loss of voice	_____

Swollen or discoloured tongue , gums, lips	_____

Mouth ulcers or Sore gums	_____
	TOTAL
	______


LUNGS

Chest congestion or Productive chest cough	_____

Asthma – wheezing or coughing spasms	_____

Shortness of breath or Difficulty breathing	_____

Recurrent or chronic bronchitis	_____
	TOTAL
	______


HEART

Irregular or skipped heartbeat	_____

Rapid or pounding heartbeat	_____

Chest pain	_____
	TOTAL
	______


HEAD

Headaches	_____

Faintness or lightheadedness	_____

Dizziness or vertigo	_____

Insomnia or sleep disturbance	_____
	TOTAL
	______


APPETITE EATING BEHAVIOUR

Loss of appetite	_____

Food Cravings	_____

Binge eating / drinking or Compulsive eating	_____

Excessive weight or weight gain	_____
	TOTAL
	______


DIGESTIVE TRACT

Episodic nausea or vomiting	_____

Diarrhea - Episodic or recurrent	_____

Constipation – episodic or recurrent	_____

Abdominal Bloating – episodic or recurrent	_____

Flatulence – burping, or passing gas	_____

Heartburn – episodic or recurrent	_____

Indigestion or abdominal discomfort/pain	_____
	TOTAL
	______


SKIN

Acne	_____

Hives, rashes, or dry skin	_____

Hair Loss	_____

Flushing or hot flushes	_____

Excessive sweating	_____
	TOTAL
	______

JOINTS / MUSCLES

Pain or aches in the joints or arthritis	_____
Pain or aches in muscles	_____
Stiffness or limitation of movement	_____
Feeling of weakness or tiredness	_____
	TOTAL
	______


ENERGY / ACTIVITY

Fatigue, sluggishness or lethargy	_____

Apathy or Loss of motivation	_____

Hyperactivity or Restlessness	_____
	TOTAL
	______


MIND / COGNITION

Poor memory	_____

Confusion, poor comprehension	_____

Poor concentration	_____

Poor physical coordination	_____

Difficulty in making decisions	_____

Stuttering or Stammering or Slurred speech	_____

Learning disabilities	_____
	TOTAL
	______


EMOTIONS / FEELINGS

Mood swings	_____

Anxiety, fear or nervousness	_____

Anger, irritability, or aggressiveness	_____

Depression	_____
	TOTAL
	______


OTHER

Recent illness or Recurrence of illness	_____

Underweight or Rapid weight loss	_____

Fluid or Water retention	_____

Frequent or urgent urination	_____

Genital itch or discharge	_____
	TOTAL
	______

GRAND TOTAL	______

SIGNATURE:	___________________________________

DATE:	___________________________________

Please Print out the form using the print button on the top right of this page and send to:

Massey Amcal Pharmacy
396 Don Buck Road
Massey
Auckland

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