MSQ Page

Instructions

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

Medical Symptoms Questionnaire

Your holistic lifestyle change body tracker for every roadmap phase.

Patient name

Your Email

Date

Head

Headache

Faintness

Dizziness

Insomnia

Eyes

Watery or Itchy Eyes

Bags or dark circles under eyes

Swollen, reddened, or sticky eyelids

Blurred or tunnel vision (doesn’t include nearsightedness or farsightedness)

Ears

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Nose

Stuffy nose

Hay fever

Excessive mucus formation

Sinus problems

Sneezing attacks

Digestive Tract

Nausea or Vomiting

Diarrhea

Constipation

Bloated feeling

Belching or passing gas

Heartburn

Intestinal/Stomach pain

Mouth/Throat

Chronic coughing

Gagging, frequent need to clear throat

Soar throat, hoarseness, loss of voice

Swollen/discolored tongue, gum, lips

Canker Sores

Heart

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Emotions

Mood swings

Anxiety, fear or nervousness

Anger, irritability, or aggresiveness

Depression

Joint/Muscles

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

Skin

Acne

Hives , rashes, or dry skin

Hair loss

Flushing or hot flushes

Excessive Sweating

Energy/Activity

Fatigue, Slugishness

Apathy, Lethargy

Hyperactivity

Restlessness

Lungs

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficult breathing

Weight

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

Mind

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Other

Frequent illness

Frequent or urgent urination

Genital itch or discharge

I hereby certify that, to the best of my knowledge, the information provided is true and accurate to support my fertility journey with Fertile Ground’s roadmap.

Head

Headaches