If yes please select one of the follow statements
Please answer the questions below based on over the last 2 weeks and how often you have been bothered by any of these problems.
The following questions are marked on a scale of 0-8 depending on how much you avoid the circumstances described.
0 = Would not avoid it, 2 = Slightly avoid it, 4 = Definitely avoid it, 6 = Markedly avoid it, 8 = Always avoid it.
In-between answers (1, 3, 5, 7 are allowed)
Your medical records will be updated with the information provided in this form