Please use this scale to rate the frequency and severity of symptoms you have experienced over the past two years. 
If multiple choices are given, please specify what applies in the comment column.

• Leave the score blank if you Never have the symptom.                          
• Use a 1 if you Occasionally have it and the effect is Mild.
• Use a 2 if you Occasionally have it and the effect is Severe.
• Use a 3 if you Frequently or Consistently have it and the effect is Mild
• Use a 4 if you Frequently or Consistently have it and the effect is Severe.