*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.
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
Thank you for submitting your Follow Up Symptom Questionnaire!
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