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Please read the following instructions carefully. What follows is a list of medical symptoms that people sometimes have. Please indicate:
(A) How frequently you have the symptom, if at all. Circle a number on a scale of 0 to 7.
(B) The degree of discomfort caused by each symptom you have. Select a number on a scale of 0 to 10.
(C) The degree of interference caused by each symptom you have, that is, how much it interferes with your daily activities. Select a number on a scale of 0 to 10.
(A) FREQUENCY
| 0 |
= |
Never or almost never |
| 1 |
= |
Less than once a month |
| 2 |
= |
Once to twice a month |
| 3 |
= |
About once a week |
| 4 |
= |
2 to 3 times a week |
| 5 |
= |
4 to 6 times a week |
| 6 |
= |
Once a day |
| 7 |
= |
More than once a day |
SYMPTOM
| 1. |
Headache |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 2. |
Visual symptoms (blurred or double vision) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 3. |
Dizziness or feeling faint |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 4. |
Numbness |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 5. |
Ringing in the ears |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 6. |
Nausea |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 7. |
Vomiting |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 8. |
Constipation |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 9. |
Loose stools |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 10. |
Discomfort with urination (pressure, burning) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 11 |
Abdominal or stomach discomfort like pressure,
burning, or cramping not related to menstruation |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 12. |
Aching muscles |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 13 |
Aching joints |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 14. |
Aching back |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 15. |
Discomfort in limb(s) (burning, aching) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 16. |
Chest pain (burning, pressure, tightness) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 17. |
Palpitations |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 18. |
Excessive sweating |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 19. |
Shortness of breath |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 20. |
Coughing |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 21. |
Wheezing |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 22. |
Skin problems (rash, itching |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 23. |
Teeth grinding |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 24. |
Sleeping difficulties |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 25. |
Fatigue |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 26. |
Other: (Fill in) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
WOMEN ONLY
| 1. |
Vaginal infection or irritation |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 2. |
Menstrual irregularities |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 3. |
Menstrual pain |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 4. |
Premenstrual tension |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 5. |
Premenstrual pain |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
(B) DEGREE OF DISCOMFORT
Choose a number from 0-10 where 0 means no discomfort, and 10 denotes severe pain
SYMPTOM
| 1. |
Headache |
------- |
| 2. |
Visual symptoms |
------- |
| |
(blurred or double vision) |
------- |
| 3. |
Dizziness or feeling faint |
------- |
| 4. |
Numbness |
------- |
| 5. |
Ringing in the ears |
------- |
| 6. |
Nausea |
------- |
| 7. |
Vomiting |
------- |
| 8. |
Constipation |
------- |
| 9. |
Loose stools |
------- |
| 10. |
Discomfort with urination
(pressure, burning) |
------- |
| 11. |
Abdominal or stomach discomfort
(pressure, burning, cramping not related to menstruation) |
------- |
| 12. |
Aching muscles |
------- |
| 13. |
Aching joints |
------- |
| 14. |
Aching back |
------- |
| 15. |
Discomfort in limb(s)
(burning, aching) |
------- |
| 16. |
Chest pain
(burning, pressure, tightness) |
------- |
| 17. |
Palpitations |
------- |
| 18. |
Excessive sweating |
------- |
| 19. |
Shortness of breath |
------- |
| 20. |
Coughing |
------- |
| 21. |
Wheezing |
------- |
| 22. |
Skin problems
(rash, itching) |
------- |
| 23. |
Teeth grinding |
------- |
| 24. |
Sleeping difficulties |
------- |
| 25. |
Fatigue |
------- |
| 26. |
Other: (Fill in) |
------- |
| |
|
------- |
| |
|
------- |
| |
|
------- |
WOMEN ONLY
| 1. |
Vaginal infection or irritation |
------- |
| 2. |
Menstrual irregularities |
------- |
| 3. |
Menstrual pain |
------- |
| 4. |
Premenstrual tension |
------- |
| 5. |
Premenstrual pain |
------- |
(C) DEGREE OF INTERFERENCE
Indicate how much it interferes with your daily activities. Select a number on a scale of 0 to 10 where 0 means no interference and 10 denotes severe interference.
SYMPTOM
| 1. |
Headache |
------- |
| 2. |
Visual symptoms |
------- |
| |
(blurred or double vision) |
------- |
| 3. |
Dizziness or feeling faint |
------- |
| 4. |
Numbness |
------- |
| 5. |
Ringing in the ears |
------- |
| 6. |
Nausea |
------- |
| 7. |
Vomiting |
------- |
| 8. |
Constipation |
------- |
| 9. |
Loose stools |
------- |
| 10. |
Discomfort with urination
(pressure, burning) |
------- |
| 11. |
Abdominal or stomach discomfort
(pressure, burning, cramping not related to menstruation) |
------- |
| 12. |
Aching muscles |
------- |
| 13. |
Aching joints |
------- |
| 14. |
Aching back |
------- |
| 15. |
Discomfort in limb(s)
(burning, aching) |
------- |
| 16. |
Chest pain
(burning, pressure, tightness) |
------- |
| 17. |
Palpitations |
------- |
| 18. |
Excessive sweating |
------- |
| 19. |
Shortness of breath |
------- |
| 20. |
Coughing |
------- |
| 21. |
Wheezing |
------- |
| 22. |
Skin problems
(rash, itching) |
------- |
| 23. |
Teeth grinding |
------- |
| 24. |
Sleeping difficulties |
------- |
| 25. |
Fatigue |
------- |
| 26. |
Other: (Fill in) |
------- |
| |
|
------- |
| |
|
------- |
| |
|
------- |
WOMEN ONLY
| 1. |
Vaginal infection or irritation |
------- |
| 2. |
Menstrual irregularities |
------- |
| 3. |
Menstrual pain |
------- |
| 4. |
Premenstrual tension |
------- |
| 5. |
Premenstrual pain |
------- |
There is a big difference between having a symptom that interferes with your life and one that you can live with. In reviewing what symptoms bother you the most, pay close attention to interference. When you take the test again later, compare each symptom that you have reported on all dimensions—frequency, severity, and degree of interference with your life. When in doubt, always consult a physician.
Copyright © Jane Leserman, Ph.D., and Claudia Dorrington, 1986.
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