IFM MSQ (Medical Symptoms Questionnaire) is a questionnaire from the Institute for Functional Medicine designed to assess overall health by analyzing symptoms. It:
- helps identify hidden imbalances and burdens in the body (digestion, hormones, immunity, toxic load, etc.);
- allows tracking changes in condition before and after treatment or lifestyle changes;
- is used as a starting tool for creating an individualized plan for nutrition, supplements, and therapy.
Evaluate each of the following symptoms based on your health over the last 14 days.
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IFM: Medical Symptoms Questionnaire
| First Name | Date |
Please rate each of the following symptoms based on your typical health profile over the past 14 days.
| HEAD | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Headaches | |||||
| Faintness | |||||
| Dizziness | |||||
| Insomnia | |||||
| Section total | |||||
| EYES | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Watery or itchy eyes | |||||
| Swollen, reddened, or sticky eyelids | |||||
| Bags or dark circles under eyes | |||||
| Blurred or tunnel vision (excludes near-/far-sightedness) | |||||
| Section total | |||||
| EARS | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Itchy ears | |||||
| Earaches, ear infections | |||||
| Ear discharge | |||||
| Ringing in ears, hearing loss | |||||
| Section total | |||||
| NOSE | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Nasal congestion | |||||
| Sinus problems | |||||
| Hay fever | |||||
| Sneezing attacks | |||||
| Excessive mucus formation | |||||
| Section total | |||||
| MOUTH / THROAT | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Chronic coughing | |||||
| Gagging or frequent need to clear the throat | |||||
| Sore throat, hoarseness, loss of voice | |||||
| Swollen or discolored tongue, gums, lips | |||||
| Canker sores | |||||
| Section total | |||||
| SKIN | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Acne | |||||
| Hives, rashes, dry skin | |||||
| Hair loss | |||||
| Flushing, hot flashes | |||||
| Excessive perspiration | |||||
| Section total | |||||
| HEART | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Irregular or skipped heartbeat | |||||
| Rapid or pounding heartbeat | |||||
| Chest pain | |||||
| Section total | |||||
| LUNGS | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Chest congestion | |||||
| Asthma, bronchitis | |||||
| Shortness of breath | |||||
| Difficulty breathing | |||||
| Section total | |||||
| DIGESTION | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Nausea, vomiting | |||||
| Diarrhea | |||||
| Constipation | |||||
| Bloating sensation | |||||
| Belching, passing gas | |||||
| Heartburn | |||||
| Intestinal / stomach pain | |||||
| Section total | |||||
| JOINTS / MUSCLES | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Joint pain or aches | |||||
| Arthritis | |||||
| Stiffness or limitation of movement | |||||
| Muscle pain or aches | |||||
| Sensation of weakness or fatigue | |||||
| Section total | |||||
| WEIGHT | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Overeating / binge drinking | |||||
| Cravings for certain foods | |||||
| Overweight | |||||
| Compulsive overeating | |||||
| Water retention | |||||
| Underweight | |||||
| Section total | |||||
| ENERGY / ACTIVITY | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Fatigue, sluggishness | |||||
| Apathy, listlessness | |||||
| Hyperactivity | |||||
| Restlessness | |||||
| Section total | |||||
| MIND | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Poor memory | |||||
| Confusion, poor comprehension | |||||
| Poor concentration | |||||
| Poor physical coordination | |||||
| Difficulty making decisions | |||||
| Stuttering or stammering | |||||
| Slurred speech | |||||
| Difficulty learning | |||||
| Section total | |||||
| EMOTIONS | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Mood swings | |||||
| Anxiety, fear, nervousness | |||||
| Anger, irritability, aggressiveness | |||||
| Depression | |||||
| Section total | |||||
| OTHER | |||||
| almost never | sometimes, mild effect | sometimes, significant effect | often, mild effect | often, significant effect | |
| Frequent illnesses | |||||
| Frequent or urgent urination | |||||
| Genital itch or discharge | |||||
| Total of all sections | |||||
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