All rights reserved. Questionnaire may be copied but not altered, sold, or placed on another website. Please reproduce and distribute freely for clinic or patient use. Please offer any constructive suggestions or criticism.
Recommendations are evidence based and from current leading sources.
Print the 3 page questionnaire, check answers to the questions that apply to you, and take to your doctor. Answers checked in the right column may indicate a need for further counseling, evaluation or treatment. Now, take this questionnaire to your health care provider. Answers in the right hand column will be discussed with you and further counseling, evaluation or treatment may be necessary.