Rate symptom burden: Head (Headaches, dizziness, insomnia) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Eyes (Watery/itchy eyes, dark circles) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Ears (Itchy ears, ringing/hearing loss) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Nose (Stuffy nose, sinus problems, sneezing) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Mouth/Throat (Chronic coughing, sore throat) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Skin (Acne, rashes, dry skin, sweating) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Heart (Irregular or rapid heartbeat) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Lungs (Chest congestion, breathing difficulty) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Digestive (Nausea, diarrhea, bloating, gas) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Joints/Muscles (Joint/muscle pain, stiffness) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Energy (Fatigue, sluggishness, restlessness) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Mind (Poor memory, concentration, decisions) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

Rate symptom burden: Emotions (Mood swings, anxiety, depression) (0=None, 10=Severe) * Required

1 2 3 4 5 6 7 8 9 10

ND - MSQ Medical Symptoms Questionnaire

Multi-System Symptom Burden Assessment