Below is a list of phrases that describe certain feeling that people have. Rate the patients by finding the answer which best describes the extent to which he/she has these conditions. Select one of the five responses for each of the fourteen questions.
This is to notify your provider
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By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents. I agree that the above information is true and accurate to assist with the medical diagnosis.
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