Follow Up Visit Symptom Questionnaire

*Please only complete this form if you are a returning patient that has already completed a new patient appointment

Print, then fill out the questionnaire here. Please bring the completed form to your next appointment.

Rate each of the symptoms on the questionnaire based on your typical health profile for the past 14 days.

Point Scale:

0-Never or almost never have the symptom

1-Occasionally have it, effect is not severe

2-Occasionally have it, effect is severe

3-Frequently have it, effect is not severe

4-Frequently have it, effect is severe