Please indicate how much the following problems have bothered your friend or loved one during the past week. Mark only one box for each problem, and be sure to answer all items.
Even though these conversations may be difficult, your friend or loved one may want to print this page out so that they could use it as a potential conversation starter with their healthcare provider.
*This screen does not take the place of a physician's diagnosis. Patients are strongly urged to seek the advice of your physician or a qualified therapist prior to starting any new treatment or therapy or with any questions you may have regarding a medical, mental, or emotional condition.
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