Please fill in the following form completely. Score every symptom based on your experience over last 30 days. Using the SCALE OF SYMPTOM POINTS listed below, FILL IN the appropriate score in the corresponding field for EVERY symptom listed.
Not Applicable = If you don't suffer from this ever or almost ever.
1 = Suffered OCCASSIONALLY (less than 2 times per week), symptom wasn't severe
2 = Suffered FREQUENTLY (2 or more times per week), symptom wasn't severe
3 = Suffered OCCASSIONALLY, symptom was severe
4 = Suffered FREQUENTLY, symptom was severe