Medical Symptoms Questionnaire

This Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify underlying causes of illness and helps us track your progress. Rate each of the following symptoms based upon your typical health profile for the past 30 days. Please total your scores within each section and at the bottom of the page

Step 1: General Information

Form Image

Name *
Date of Birth *
Date *

Step 2:

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

Head

Headaches *
Faintness *
Dizziness *
Insomnia *
Total:

Eyes

Watery or itchy eyes *
Swollen, reddened or sticky eyelids *
Bags or dark circles under eyes *
Blurred or tunnel vision (does not include near- or far-sightedness) *
Total:

Ears

Itchy ears *
Earaches, ear infections *
Drainage from ear *
Ringing in ears, hearing loss *
Total:

Nose

Stuffy nose *
Sinus problems *
Hay fever *
Sneezing attacks *
Excessive mucus formation *
Total:

Mouth / Throat

Chronic coughing *
Gagging, frequent need to clear throat *
Sore throat, hoarseness, loss of voice *
Swollen or discolored tongue, gums or lips *
Canker sores *
Total:

Skin

Acne *
Hives, rashes, dry skin *
Hair loss *
Flushing, hot flashes *
Excessive sweating *
Total:

Heart

Irregular or skipped heartbeat *
Rapid or pounding heartbeat *
Chest pain *
Total:

Lungs

Chest congestion *
Asthma, bronchitis *
Shortness of breath *
Difficulty breathing *
Total:

Digestive Tract

Nausea, vomiting *
Diarrhea *
Constipation *
Bloated feeling *
Belching, passing gas *
Heartburn *
Intestinal/stomach pain *
Total:

Joints/ Muscles

Pain or aches in joints *
Arthritis *
Stiffness or limitation of movement *
Pain or aches in muscles *
Feeling of weakness or tiredness *
Total:

Weight

Binge eating/drinking *
Craving certain foods *
Excessive weight *
Compulsive eating *
Water retention *
Underweight *
Total:

Energy/Activity

Fatigue, sluggishness *
Apathy, lethargy *
Hyperactivity *
Restlessness *
Total:

Mind

Poor memory *
Confusion, poor comprehension *
Poor concentration *
Poor physical coordination *
Difficulty in making decisions *
Stuttering or stammering *
Slurred speech *
Learning disabilities *
Total:

Emotions

Mood swings *
Anxiety, fear, nervousness *
Anger, irritability, aggressiveness *
Depression *
Total:

Other

Frequent illness *
Frequent or urgent urination *
Genital itch or discharge *
Total:

Overall Total

Total:

Select below *
Optimal < 10Mild Toxicity 10-50Moderate Toxicity 50-100Severe Toxicity >100

Step 3: Review of Current / Recent Symptoms

General

Fatigue
YesNo
Fever
YesNo
Night sweats
YesNo
Sleep disturbance
YesNo
Weight gain
YesNo
Weight loss
YesNo

Ophthalmologic

Discharge
YesNo

Dry eye
YesNo

Itching and redness
YesNo

Pain
YesNo

ENT

Hoarseness
YesNo

Nasal Congestion
YesNo

Snoring
YesNo

Decreased hearing
YesNo

Difficulty swallowing
YesNo

Nosebleed
YesNo

Sore throat
YesNo

Swollen glands
YesNo

Endocrine

Cold intolerance
YesNo

Excessive sweating
YesNo

Excessive thirst
YesNo

Heat intolerance
YesNo

Respiratory

Chest pain
YesNo

Cardiovascular

Dizziness
YesNo

Shortness of breath
YesNo

Gastrointestinal

Abdominal pain
YesNo

Change in bowel habits
YesNo

Constipation
YesNo

Diarrhea
YesNo

Heartburn
YesNo

Nausea
YesNo

Women Only

Decreased Libido
YesNo

Heavy bleeding
YesNo

Hot flashes
YesNo

Irregular menses
YesNo

Missed periods
YesNo

Genitourinary

Blood in urine
YesNo

Change in bladder habits
YesNo

STD concerns
YesNo

Musculoskeletal

Joint stiffness
YesNo

Muscle aches
YesNo

Weakness
YesNo

Skin

Acne
YesNo

Changes in moles
YesNo

Rash
YesNo

Skin lesion(s)
YesNo

Neurologic

Balance difficulty
YesNo

Dizziness
YesNo

Headache
YesNo

Memory loss
YesNo

Tingling/Numbness
YesNo

Transient loss of vision
YesNo

Tremor
YesNo

Psychiatric

Mood swings
YesNo

Problems with focus
YesNo

Anxiety
YesNo

Depressed mood
YesNo

Difficulty sleeping
YesNo

Eating disorder
YesNo

Mental or Physical abuse
YesNo

Substance abuse
YesNo

To help us make the most of your visit today, please identify the top 3 concerns/issues that we need to address today:

Please let us know TODAY, if you have any medications needing refills. We can no longer accept phone calls for refills. If you do not make the request today, you will need to make an office visit to address that request.

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Phone: (817) 886-0042

Email: info@collaborativewellnesscenter.com

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1124 Glade Road, Suite 120 Colleyville, Texas 76034

(817) 886-0042

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