Health Symptoms Questionnaire

0 / 70

Before we begin

Rate your symptoms from the past week

Fifteen short sections, about three minutes. Your answers stay on this device until you or your provider print or copy the summary.

The point scale

  • 0Never or almost never have the symptom
  • 1Occasionally have it, effect is not severe
  • 2Occasionally have it, effect is severe
  • 3Frequently have it, effect is not severe
  • 4Frequently have it, effect is severe

Nothing is sent anywhere. Answers are saved in this browser only, so you can close the page and pick up where you left off.

Your summary

Show this screen to your provider, or print it for your chart.

Grand total
0
0 of 70 answered

Rated 2 or higher

    This questionnaire records how you feel; it is not a diagnosis. Talk through the results with your provider.