Health Survey

What is your Total Symptom Burden load?

Find out with our health profile questionnaire.

Take the questionnaire below and get a free analysis of your symptoms with an EPIC team member.

  • The Medical Symptoms Questionnaire (MSQ) identifies symptoms that help to determine the underlying causes of illness, and helps us track your progress over time.
  • The Thyroid/Adrenal Symptoms Questionnaire (TSQ) does the same, but focuses specifically on symptoms related to thyroid and/or adrenal dysfunction.

Total time to take the questionnaire is about 5 minutes. First, fill out your contact information, then you will find directions on how to take the survey. The first survey is the Medical Symptoms Questionnaire, the second survey is the Thyroid/Adrenal Symptoms Questionnaire. Your Total Symptom Burden Load will be calculated for you and discussed on a free Discovery Call.

Contact Information

Part 1: Multi Symptom Questionnaire

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Digestive Tract

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Ears

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Emotions

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Energy/Activity

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Eyes

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Heart

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Joints/Muscles

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Lungs

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Mind

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Mouth/Throat

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Nose

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Skin

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Weight

Rate each of the following symptoms based upon your typical health profile the past 30 days

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

Other

Part 2: Thyroid Symptom Questionnaire

This questionnaire helps you determine the function of thyroid hormone in your body. Regardless if you have had a lab test that say your thyroid is normal or that you may be taking prescription thyroid medication, you still may have problems with metabolism that directly relate to how thyroid hormone is functioning in your body.

In front of each question score the following from 0-10

For example,

10 = If this is a noticeable issue or significant problem nearly all the time;

7 = this is a noticeable issue or significant problem some of the time;

5 = If this is a problem you are aware of, but not a major issue in your life currently;

2 = If this happens every now and then, but you don't notice it too much and are not concerned;

0 = If you rarely or never have this issue

Step 3: Schedule Your Discovery Call to discuss your results

You will be redirected to schedule on the next page after you hit SUBMIT

The EPIC Team is ready to help you get your health back on track. Take the first step today!

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