Medical Questionnaire – Multiple Symptom Questionnaire (MSQ) - CMIE

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This multiple symptom screening questionnaire allows us to better understand your health status. The score will be used as follow-up progresses to assess the symptom burden present and the improvement observed.

Write down the intensity of each symptom present in the last month, depending on your state of health.
Head
Headaches
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Weakness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Dizziness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Insomnia
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Eyes
Watery or itchy eyes
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Swollen, reddened, or sticky eyelids
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Dark puffiness or dark circles under the eyes
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Blurred vision or restricted field of vision (does not include near or far vision)
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Ears
Itchy ears
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Earache, infection
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Discharge from the ear
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Ringing in the ears, hearing loss
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Nose
Nasal obstruction
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Sinus pain or congestion
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Excessive mucus formation
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Sneezing fits
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Hay fever
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Mouth / Throat
Chronic cough
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Coughing, frequent need to clear throat
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Irritated throat, hoarseness, loss of voice
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Discolored or swollen lips, gums, or tongue
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Mouth ulcers
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Skin
Acne
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Hives, rash, dry skin
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Hair loss
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Redness, hot flashes
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Excessive sweating
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Heart
Irregular or missing heartbeat
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Rapid heartbeat or pounding
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Chest pain
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Lungs
Chest congestion
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Asthma, bronchitis
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Breathlessness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Difficulty breathing
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Digestive system
Nausea, vomiting
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Diarrhoea
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Constipation
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Belching (discharge of gas through the mouth)
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Éructations (rejet de gaz par la bouche)
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Intestinal gas
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Heartburn
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Abdominal pain
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Joints/Muscles
Joint pain/aches
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Arthritis
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Stiffness/short range of motion
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Feeling weak or tired
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Weight
Food/beverage abuse
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Craving for certain foods
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Excessive weight
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Compulsive Eating
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Water Retention
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Underweight
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Energy
Tiredness, laziness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Apathy, lethargy
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Hyperactivity
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Restlessness / nervousness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Thoughts
Lack of memory
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Confusion, difficulty understanding
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Difficulty concentrating
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Difficulty in coordination
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Difficulty making decisions
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Stammer
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Slurred speech
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Learning Disabilities
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Emotions
Mood swings
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Anxiety, fear, nervousness
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Anger, irritability, aggression
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Depression
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Other
Often sick
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Urgent and frequent need to urinate
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
Genital itching or discharge
- Symptom never or almost never experienced
- Rarely and/or slightly
- Occasionally and/or moderately
- Frequently and/or moderately
- Very frequently and/or severely
CAPTCHA

Head

Eyes

Ears

Nose

Mouth / Throat

Skin

Heart

Lungs

Digestive system

Joints/Muscles

Weight

Energy

Thoughts

Emotions

Other