Institute for the Study of
Healthcare Organizations & Transactions

Items of the

Medical Problems and Complaints Questionnaire

  1. Vomiting (WOMEN: when you weren't pregnant).
  2. Abdominal or belly pain (WOMEN: when you weren't menstruating).
  3. Nausea (feeling sick to your stomach, but not actually vomiting).
  4. Excessive gas or bloating of your stomach or abdomen.
  5. Loose bowels or diarrhea.
  6. Foods you cannot eat because they make you sick.
  7. Pain in your arms or legs (other than the joints).
  8. Back pain.
  9. Pain in your joints.
  10. Pain when you urinate.
  11. Other pains (do not count headaches).
  12. Shortness of breath (when not really exerting yourself).
  13. Heart racing, pounding, or skipping.
  14. Chest pain.
  15. Dizziness.
  16. Amnesia, a period of several hours or days after which you could not remember what happened.
  17. Trouble swallowing or lump in your throat.
  18. Losing your voice (for more than a few minutes).
  19. Complete deafness for a period of time.
  20. Double vision for a period of time.
  21. Blurred vision (when you did not need glasses).
  22. Complete blindness for more than a few seconds.
  23. Fainting spells or loss of consciousness (except due to diagnosed epilepsy).
  24. Seizures or convulsions (except due to diagnosed epilepsy).
  25. Trouble walking (or other impairment of coordination or balance).
  26. Paralysis, or periods of weakness when you could not lift or move things normally.
  27. Complete inability to urinate for a whole day (other than after childbirth or surgery).
  28. Burning sensations in your sexual organs or rectum (other than during sexual intercourse).
  29. Your sex life is unimportant to you, and you feel you could get along all right without it.
  30. Sex is often physically painful.
  31. Other sexual problems (MEN: such as not being able to obtain an erection or to ejaculate).
  32. WOMEN: Very painful menstrual periods (other than during your first year of menstruation).
  33. WOMEN: Irregular menstrual periods (other than during your first year of menstruation, or during menopause).
  34. WOMEN: Excessive bleeding during menstrual periods.
  35. WOMEN: Vomiting throughout one or more pregnancies.