Form 10 Wellness Survey Screenshot

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
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currently valid OMB control number. Send comments regarding this burded estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockl edge Dri ve, MSC 7974, Bethesda, MD 20892-7974, AT T N: PRA (0925xxxx).

Study name

Subje ct numbe r

Date (mm/dd/yyyy)

Time (24 hour clock)

Experimenter initials

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We llne ss Surv e y

Se le ct one option for e ach symptom to indicate whe the r that symptom applie s to you right now.

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Ge ne ral Discomfort
None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

Slight

Moderate

Severe

None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

Slight

Moderate

Severe

Fatigue

He adache

Eye Strain

Difficulty Focusing
None

Saliv ation Incre ase d

Swe ating

Nause a

Difficulty Conce ntrating
None

“Fullne ss of the He ad” - Fullne ss of the he ad is an aware ne ss of pre ssure in the he ad.
None

Slight

Moderate

Severe

Slight

Moderate

Severe

Slight

Moderate

Severe

Slight

Moderate

Severe

Blurre d Vision
None

Dizzine ss with Eye s Ope n
None

Dizzine ss with Eye s Close d
None

Ve rtigo - Ve rtigo is e xpe rie nce d as loss of orie ntation with re spe ct to v e rtical upright.
None

Slight

Moderate

Severe

Stomach Aware ne ss - Stomach aware ne ss is a fe e ling of discomfort which is just short of nause a.
None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

None

Slight

Moderate

Severe

Burping

Vomiting

Are you e xpe rie ncing any othe r symptoms RIGHT NOW?
Yes
No

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What othe r symptom are you e xpe rie ncing?

How se v e re is your othe r symptom?
Slight

Moderate

Severe

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Thank you for comple ting our que stionnaire .
At this time , ple ase notify the e xpe rime nte r that you hav e finishe d.

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Experimenter initials

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We thank you for your tim e s pent taking this s urvey.
Your res pons e has been recorded.

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