DIRECTIONS: Choose the response that best describes the FREQUENCY and SEVERITY of your symptoms. LEAVE THE QUESTION BLANK if you never experience the symptom. You may find the same symptom in different sections. Please try to keep your answers consistent in each section for a particular symptom.  These questions are for information only and are not meant to treat or diagnose a specific disease or condition.


  • 1 = Occasionally have it, effect not severe
  • 2 = Occasionally have it, effect is severe
  • 3 = Frequently have it, effect is not severe
  • 4 = Frequently have it, effect is severe
  • LEAVE BLANK = You never experience the symptom