Problem   

Please use the following number scale to rank how severe your problem was during the last month. Use any number between 0 to 10 (0 for none to 10 for unbearable). This number will be called severity. Enter it in the box below.

                    0       1        2          3        4        5         6         7        8         9       10
               l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __l__ __I

0 None         2 Mild       4 Bad        6 Very Bad        8 Excruciating      10 Unbearable

Severity   

Where is this problem bothering you? Your upper back, bottom of foot, all over etc. ?
Location   

How often during the last month did it bother you? Estimate the number of days during the month or actually keep track. Give us a number here from 0 to 30.
Frequency

How much did you spend in the last month on this problem?
Cost         

Refers to the level of research you have selected.  (1,2,3,4,5)
Level        
You only need to complete your address information for level 1-4 so tools may be forwarded.

*Name       

*e-mail       

Address   

  City           

State        

Zip            

Any other comments

*Required on all submissions. Fill out one form for each symptom.