Symptoms Impact Questionnaire

  • Date Format: MM slash DD slash YYYY
  • Initial3 Months6 Months9 Months12 Months
  • Measuring Activities

    For each of the following 9 questions, check the box that best indicates how much difficulty you have in performing each of the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can't perform an activity check the last option.

    0 is No Difficulty and 10 is Very Difficult

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    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
  • 012345678910
    0 is No Difficulty and 10 is Very Difficult
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    0 is No Difficulty and 10 is Very Difficult
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    0 is No Difficulty and 10 is Very Difficult
  • Measuring Impact

    For each of the following 2 questions, check the box that best describes the overall impact of any medical problem over the last 7 days.

    0 is Never and 10 is Always
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    0 is Never and 10 is Always
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    0 is Never and 10 is Always
  • Measuring Symptoms

    For each question, check the box that best indicates the intensity of the following symptoms over the past 7 days

    0 is Low and 10 is High
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    0 is Low and 10 is High
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    0 is Low and 10 is High
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    0 is Low and 10 is High
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    0 is Awoke Well Rested and 10 is Awoke Very Tired
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    0 is No Depression and 10 is Very Depressed
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    0 is Good Memory and 10 is Poor Memory
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    0 is Not Anxious and 10 is Very Anxious
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    0 is No Tenderness and 10 is Very Tender
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    0 is No Imbalance and 10 is Severe Imbalance
  • 012345678910
    0 is No Sensitivity and 10 is Extreme Sensitivity
  • This field is for validation purposes and should be left unchanged.