Medical Symptoms Questionnaire
Email address *
First Name *
Your answer
Last Name *
Your answer
Head
Headaches *
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
Never or Almost Never Happens
Frequently happens, Effect is Severe
Faintness *
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
Dizziness/Vertigo *
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
Insomnia *
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
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