1 Numbness or tingling in hands or feet |
0 |
1 |
2 |
3 |
4 |
2 Dizziness or light-headedness |
0 |
1 |
2 |
3 |
4 |
3 Fever, chills |
0 |
1 |
2 |
3 |
4 |
4 Rash, itching or other skin problem |
0 |
1 |
2 |
3 |
4 |
5 Common cold, sinus symptoms |
0 |
1 |
2 |
3 |
4 |
6 Earache, draining ear, hearing problem |
0 |
1 |
2 |
3 |
4 |
7 Eye trouble, problem with vision |
0 |
1 |
2 |
3 |
4 |
8 Nightmares |
0 |
1 |
2 |
3 |
4 |
9 Losing weight or weight loss |
0 |
1 |
2 |
3 |
4 |
10 Toothache, dental caries |
0 |
1 |
2 |
3 |
4 |
11 Painful oral lesion, difficulty swallowing |
0 |
1 |
2 |
3 |
4 |
12 Loss of appetite |
0 |
1 |
2 |
3 |
4 |
13 Nausea, vomiting |
0 |
1 |
2 |
3 |
4 |
14 Diarrhoea |
0 |
1 |
2 |
3 |
4 |
15 Worrying about one’s appearance |
0 |
1 |
2 |
3 |
4 |
16 Bed wetting |
0 |
1 |
2 |
3 |
4 |
17 Failure to take regular medications |
0 |
1 |
2 |
3 |
4 |