For each area, you'll rate how you've been feeling using the scale below. Your care team will review your responses before you arrive so your time together is as meaningful as possible.
NA
Not applicable — this doesn't apply to you or you haven't experienced it
1
Minimal — barely noticeable, doesn't affect your day at all
2
Mild — present and noticeable, but easy to manage or push through
3
Moderate — noticeable and sometimes disruptive to your routine
4
Significant — frequently affecting your daily function and quality of life
5
Severe — constant disruption, significantly impacting your ability to show up day-to-day
You can add a note to any symptom for more context. You can also go back at any time to change a previous answer.
Check-in complete
Thank you for taking the time to complete this. It means a great deal to us — your care team will review everything before your visit so we can make the most of your time together.
A reminder
Is there anything else you'd like us to know?
Use the space below to share any additional context, recent changes, or anything on your mind that didn't fit into the form.