Symptoms Questionnaire

Symptoms Questionnaire

  • Please circle one of the following categories below to let us know how you are feeling at today’s appointment:

    Current Status – What are your CURRENT Symptoms?

    0 means you have no symptoms of this type at all / 1 means very mild to 0 / 5 would be moderate symptoms and 10 would mean you have severe symptoms of this type.

  • (P)Low ------------------------------------- Moderate --------------------- Severe ----------Comments, if any
  • (E)
  • (T)

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