Psychosomatic Symptom Assessment Form
Please complete the Psychosomatic Symptom Assessment Form to help us understand your current experience with psychosomatic symptoms. This form is designed to be minimal, comfortable, and easy to complete.
In a few words, what is the main psychosomatic symptom or concern you wish to assess?
*
How often have you experienced physical symptoms without a clear medical explanation in the past two weeks?
*
Never
Rarely
Sometimes
Often
Almost always
Please indicate how much the following symptoms have affected you in the past two weeks.
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Headaches
1
2
3
4
5
Stomach discomfort
6
7
8
9
10
Muscle tension
11
12
13
14
15
Fatigue
16
17
18
19
20
Palpitations
21
22
23
24
25
How would you rate the overall impact of these symptoms on your daily life?
*
1
2
3
4
5
Have you noticed any patterns or triggers that seem to increase your symptoms?
*
Yes
No
Not sure
If yes, please describe any patterns or triggers you have noticed.
How confident are you that your symptoms are related to stress or emotional factors?
*
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Have you discussed these symptoms with a healthcare professional?
*
Yes
No
If yes, what advice or recommendations were provided?
Do you feel you need further support or resources regarding your psychosomatic symptoms?
*
Yes
No
Maybe
Submit Assessment
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