Diagnosis Survey Form
Please complete the Diagnosis Survey Form to help us better understand your current situation. This survey uses a mix of rating scales and single-choice questions for a comprehensive assessment.
Overall, how would you rate your current well-being?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Which of the following best describes your main concern?
*
Physical symptoms
Emotional symptoms
Cognitive issues
Other
Please indicate the frequency of the following symptoms in the past two weeks:
*
Rows
Never
Rarely
Sometimes
Often
Always
Fatigue
1
2
3
4
5
Difficulty concentrating
6
7
8
9
10
Mood changes
11
12
13
14
15
Sleep disturbances
16
17
18
19
20
How much do your symptoms interfere with your daily activities?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
How long have you been experiencing your main concern?
*
Please Select
Less than 1 week
1-4 weeks
1-6 months
More than 6 months
Have you previously sought help for this concern?
*
Yes
No
How confident are you in managing your symptoms on your own?
Not confident
1
2
3
4
Very confident
5
1 is Not confident, 5 is Very confident
Do you feel your symptoms are improving, worsening, or staying the same?
Improving
Worsening
Staying the same
What, if anything, has helped relieve your symptoms?
Is there anything else you would like to share about your current situation?
Submit Diagnosis Survey
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