1 – Not bothered at all
2 – Bothered a little
3 – Bothered a lot
¹
1
2
3
1
Stomach pain
2
Back pain
3
Pain in your arms, legs, or joints (knees, hips, etc.)
4
Menstrual cramps or other problems with your periods
5
Headaches
6
Chest pain
7
Dizziness
8
Fainting spells
9
Feeling your heart pound or race
10
Shortness of breath
11
Pain or problems during sexual intercourse
12
Constipation, loose bowels, or diarrhea
13
Nausea, gas, or indigestion
14
Feeling tired or having low energy
15
Trouble sleeping
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.