MSQ Page - no computation – Fertile Ground Online

Instructions

Use this point scale to rate each of the following symptoms based on your typical health profile for the past 14 days:

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

*Please insert your answer here

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)

*Please insert your answer here

Ears

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

*Please insert your answer here

Nose

Stuffy nose

Hay fever

Excessive mucus formation

Sinus problems

Sneezing attacks

*Please insert your answer here

Digestive Tract

Nausea or Vomiting

Diarrhea

Constipation

Bloated feeling

Belching or passing gas

Heartburn

Intestinal/Stomach pain

*Please insert your answer here

Mouth/Throat

Chronic coughing

Gagging, frequent need to clear throat

Soar throat, hoarseness, loss of voice

Swollen/discolored tongue, gum, lips

Canker Sores

*Please insert your answer here

Heart

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

*Please insert your answer here

Emotions

Mood swings

Anxiety, fear or nervousness

Anger, irritability, or aggresiveness

Depression

*Please insert your answer here

Joint/Muscles

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

*Please insert your answer here

Skin

Acne

Hives , rashes, or dry skin

Hair loss

Flushing or hot flushes

Excessive Sweating

*Please insert your answer here

Energy/Activity

Fatigue, Slugishness

Apathy, Lethargy

Hyperactivity

Restlessness

*Please insert your answer here

Lungs

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficult breathing

*Please insert your answer here

Weight

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

*Please insert your answer here

Mind

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

*Please insert your answer here

Other

Frequent illness

Frequent or urgent urination

Genital itch or discharge

*Please insert your answer here

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