Symptom
|
Rarely
(Less than monthly)
|
Sometimes
(At
least monthly)
|
Often
(At least weekly)
|
Always
(At least daily)
|
| Anxiety/nervousness |
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| Chest pain/pressure |
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| Confusion |
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| Constipation/diarrhea |
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| Cough/congestion |
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| Depression/sadness |
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| Dizziness/vertigo |
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| Drowsiness/sleepiness |
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| Falls/accidents |
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| Fears/worries |
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| Hallucinations |
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| Headache |
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| Hearing problems |
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| High sugar/diabetes |
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| Impotence/low sexual desire |
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| Insomnia/poor sleep |
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| Itching/rash |
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| Joint aches/pains |
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| Lack of appetite |
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| Malaise/lethargy |
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| Memory problems |
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| Muscle aches/pains |
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| Nausea/indigestion |
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| Palpitations/irregular heartbeat |
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| Shortness of breath/wheezing |
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| Stiffness/rigidity |
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| Swelling/edema |
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| Tiredness/fatigue |
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| Tremors/shakiness |
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| Unsteadiness/gait problem |
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| Urine incontinence/retention |
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| Vision problems |
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| Weight gain/loss |
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| Other
(please specify): |
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