Follow Up Visit Symptom Questionnaire

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

Rate each of the following symptoms based upon 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

Name *
Name
As listed on health care coverage card
(does not included near or far-sightedness)