How do you feel today?

The following is a charting form designed to provide us with feedback to how you are feeling.

It is completely confidential and all information will be sent directly to our office. If you would like a response from us simply indicate that on the form provided. If by e-mail or direct phone call to schedule an appointment. This symptom charting is not designed as an assessment tool, but as a method to communicate your symptoms to us.

Please rate yourself on each of the following:
Attention 1 2 3 4 5 Distracted
Happy 1 2 3 4 5 Sad
Calm 1 2 3 4 5 Very Anxious
Hardworking 1 2 3 4 5 Poor Effort
No Pain 1 2 3 4 5 Pain
Not angry 1 2 3 4 5 Angry
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