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Weekly Symptoms Check List
Weekly symptom tracking. Please rate the frequency of your symptoms on average for this week.
1 = NOT AT ALL, 5 = CONSTANT. Thank you!
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Last Name
Your answer
First initial (only)
Your answer
Are you military, a veteran or a first responder?
Yes
No
Clear selection
Headaches
Not at all
1
2
3
4
5
Constantly
Clear selection
Ability to Fall Asleep
I fall asleep easily
1
2
3
4
5
I have a very hard time falling asleep
Clear selection
Ability to Stay Asleep
I am able to stay asleep
1
2
3
4
5
I constantly wake up
Clear selection
Anxiety
Not at all
1
2
3
4
5
Constantly
Clear selection
Fatigue
Not at all
1
2
3
4
5
Constantly
Clear selection
Depression
Not at all
1
2
3
4
5
Constantly
Clear selection
Easily Distracted
Not at all
1
2
3
4
5
Constantly
Clear selection
Memory Loss
Not at all
1
2
3
4
5
Constantly
Clear selection
Excessive Worry
Not at all
1
2
3
4
5
Constantly
Clear selection
Fits of Frustration or Anger
Not at all
1
2
3
4
5
Constantly
Clear selection
Feelings of Hopelessness
Not at all
1
2
3
4
5
Constantly
Clear selection
Feelings of Happiness
Not at all
1
2
3
4
5
Constantly
Clear selection
Brain Fog
Not at all
1
2
3
4
5
Constantly
Clear selection
Impulsivity
Not at all
1
2
3
4
5
Constantly
Clear selection
Overall Frequency of Pain
Not at all
1
2
3
4
5
Constantly
Clear selection
Severity of Pain
Not very painful
1
2
3
4
5
Extremely painful
Clear selection
Other symptoms and/ or comments
Your answer
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