THE ASSESSMENT

This screening questionnaire from the Institute for Functional Medicine (www.IFM.org) is used to assess and track symptoms. If this is your first time taking the Medical Symptoms Questionnaire (MSQ), rate each of the following symptoms based on your health for the past two weeks. If you are tracking recent changes, answer according to the last 48 hours. Please score from 0 to 4 according to the scale.

Medical Symptoms Questionnaire

First Name

Last Name

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Headaches

Faintness

Dizziness

Insomnia

Head Total

Watery or itchy eyes

Swollen, reddened or sticky eyelids

Bags or dark circles under eyes

Blurred or tunnel vision

Eyes Total

Itchy ears

Earaches, ear infections

Drainage from ear

Ringing in ears, hearing loss

Ears Total

Stuffy nose

Sinus problems

Hay fever

Sneezing attacks

Excessive mucus formation

Nose Total

Chronic coughing

Gagging, frequent need to clear throat

Sore throat, hoarseness, loss of voice

Swollen or discolored tongue, gums, lips

Canker sores

Mouth/Throat Total

Acne

Hives, rashes, dry skin

Hair loss

Flushing, hot flashes

Excessive sweating

Skin Total

Irregular or skipped heartbeat

Rapid or pounding heartbeat

Chest pain

Heart Total

Chest congestion

Asthma, bronchitis

Shortness of breath

Difficulty breathing

Lungs Total

Nausea, vomiting

Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain

Digestive Tract Total

Pain or aches in joints

Arthritis

Stiffness or limitation of movement

Pain or aches in muscles

Feeling of weakness or tiredness

Joints/Muscle Total

Binge eating/drinking

Craving certain foods

Excessive weight

Compulsive eating

Water retention

Underweight

Weight Total

Fatigue, sluggishness

Apathy, lethargy

Hyperactivity

Restlessness

Energy/Activity Total

Poor memory

Confusion, poor comprehension

Poor concentration

Poor physical coordination

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Mind Total

Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression

Emotions Total

Frequent illness

Frequent or urgent urination

Genital itch or discharge

Other Total

Grand Total

T: 021 241 5552

Total Health Chiropractic

Wellness Clinic

Tramway House,

Tramway Terrace,

East Douglas Village, Cork

Total Health Chiropractic Wellness Clinic

Tramway House, Tramway Terrace,

East Douglas Village, Cork

Monday

10:30 am - 2:30 pm

Tuesday

10:00 am - 10:00 pm

Wednesday

10:30 am - 9:30 pm

Thursday

10:00 am - 10:00 pm

Friday

10:30 am - 2:30 pm

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Monday

10:30 am - 2:30 pm

Tuesday

10:00 am - 10:00 pm

Wednesday

10:30 am - 9:30 pm

Thursday

10:00 am - 10:00 pm

Friday

10:30 am - 2:30 pm

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