Symptoms Questionnaire

Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years . If multiple choices are given, please specify what applies in the comment column.

• Use a 0 if you Never have the symptom.

• Use a 1 if you Occasionally have it and the effect is Mild.

• Use a 2 if you Occasionally have it and the effect is Severe.

• Use a 3 if you Frequently or Consistently have it and the effect is Mild.

• Use a 4 if you Frequently or Consistently have it and the effect is Severe.