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This survey is a tool commonly used to track the progress of a patients symptoms.  Through the information provided in this survey, you will help us guide your treatment and ensure we provide the best possible care.

The following survey would like to know how your symptoms are impacting on activities that you'd normally complete without issue.  It is essential that we collect information on 3 activities, but if your symptoms are not impacted at all, simply choose a score of 10 and make a not in the comments section at the end of the survey.

Activities that may be impacted could be running around the block, sleeping, sitting, driving your car, anything that is specific to you!

If you've completed this survey before with your current symptoms, the use of the same activities will help us to measure changes in your symptoms.

All information provided is kept strictly confidential.

Thanks in advance,

The Richmond Rehab Team.