Instructions: Please rate the severity of the following symptoms you may have experienced recently. Mark the box that best describes your experience.
Scoring: 0 = None • 1 = Mild • 2 = Moderate • 3 = Marked • 4 = Severe
Your answers stay in this browser, on this device — nothing is sent anywhere automatically. On a shared or clinic computer, use Clear form when you are finished.
0 of 11 symptoms rated
About this score. The total is the sum of all 11 items (range 0–44), and the severity category is shown only once every symptom has been rated — a partial total would understate severity. The three subtotals reflect the groupings printed on the questionnaire; the form gives no separate cut-offs for them, so none are applied. This score supports a clinical conversation — it is not a diagnosis.