Symptom Checklist
Check the number that applies to you. If a symptom doesn't apply, leave it blank. Check MILD (occurs once or twice a month), MODERATE (occurs weekly), SEVERE (occurs daily).
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  • Section 1

  • Section 2

  • Section 3

  • Section 4

  • Section 5

  • Section 6

  • Section 7 - WOMEN ONLY

  • Section 8 - WOMEN ONLY