Wellness Survey

Attachment 5

Wellness Survey

OMB Control #: 0925-xxx Expiration Date: mm/dd/yyyy

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

Study: MSD

Participant: _________

Visit: _______

Date: ________

WeLLNESS SURVEY

Directions: Circle one option for each symptom to indicate whether that symptom applies to you right now.

1. General Discomfort None Slight Moderate Severe

2. Fatigue None Slight Moderate Severe

3. Headache None Slight Moderate Severe

4. Eye Strain None Slight Moderate Severe

5. Difficulty Focusing None Slight Moderate Severe

6. Salivation Increased None Slight Moderate Severe

7. Sweating None Slight Moderate Severe

8. Nausea None Slight Moderate Severe

9. Difficulty Concentrating None Slight Moderate Severe

10. *“Fullness of the Head” None Slight Moderate Severe

11. Blurred Vision None Slight Moderate Severe

12. Dizziness with Eyes Open None Slight Moderate Severe

13. Dizziness with Eyes Closed None Slight Moderate Severe

14. **Vertigo None Slight Moderate Severe

15. ***Stomach Awareness None Slight Moderate Severe

16. Burping None Slight Moderate Severe

17. Vomiting None Slight Moderate……...Severe

18. Other _________________ None Slight Moderate……...Severe

* Fullness of the head is an awareness of pressure in the head.

**Vertigo is experienced as loss of orientation with respect to vertical upright.

***Stomach awareness is a feeling of discomfort which is just short of nausea.