Indicate if you have any of the following symptoms by rating the severity of the problem, between 1 to 10, in the column under the appropriate month. A A “1” means that the symptom is barely noticeable. A “10” means the symptom is overwhelmingly severe.
Year____
Symptom |
J
a
n |
F
e
b |
M
a
r |
A
p
r |
M
a
y |
J
u
n |
J
u
l |
A
u
g |
S
e
p |
O
c
t |
N
o
v |
D
e
c |
|
Weakness
in leg/s |
|
|
|
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|
|
|
Trouble
walking |
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|
Numbness
in legs |
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|
Tingling
in legs |
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|
Balance
disturbance |
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Walk
with assistance |
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Use
of wheelchair |
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|
Weakness
of an arm |
|
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|
Weakness
in both arms
|
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|
|
|
Numbness
in an arm |
|
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|
Tingling
in both arms |
|
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|
Overactive
reflexes |
|
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|
Blurred
vision |
|
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Double
vision |
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|
Black
spots in vision |
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|
Change
in color perception |
|
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|
Rapid
eye movements |
|
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|
Pain
in or behind the eye |
|
|
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|
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|
Vertigo
(dizziness) |
|
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|
Facial
pain |
|
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|
Facial
weakness |
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Facial
numbness |
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Impaired
speech |
|
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|
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|
&n Åü%Æ à¸æás E (@ €
ÿþDB`‘k RfÙ¼Oºå_v›P ß) left" valign="top" width="20"> |
|
|
|
|
Urinary
difficulty |
|
|
| |
|
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|
|
|
Urinary
difficulty |
|
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|
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|
Increased
urinary infections |
|
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|
|
|
Urinary
incontinence |
|
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|
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|
Mood
swings |
|
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|
Seizure
activities |
|
|
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|
Seizure
activities |
|
|
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|
|
Impotence |
|
|
|
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|
|
|
|
|
|
|
|
Male
erectile dysfunction |
|
|
|
|
|
|
|
|
|
|
|
|
|
Inability
to reach climax / ejaculation |
|
|
|
|
|
|
|
|
|
|
|
|
|
Short-term
memory loss |
|
|
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|
|
Long-term
memory loss |
|
|
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|
Other
symptoms |
|
|
|
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|
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|
BR>
Your Improvements in these Activities
Indicate if you have seen any improvement in the following activities by placing an “X” in the column under the appropriate month.
Year____
Activity |
J
a
n |
F
e
b |
M
a
r |
A
p
r |
M
a
y |
J
u
n |
J
u
l |
A
u
g |
S
e
p |
O
c
t |
N
o
v |
D
e
c |
|
Swimming |
|
|
|
|
|
|
|
|
|
|
|
|
|
Running |
|
|
|
|
|
|
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|
|
|
|
Walking |
|
|
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|
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|
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|
|
|
|
Dancing |
|
|
|
|
|
|
|
|
|
|
|
|
|
Biking |
|
|
|
|
|
|
|
|
|
|
|
|
|
Gardening |
|
|
|
|
|
|
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|
|
|
Golfing |
|
|
|
|
|
|
|
|
|
|
|
|
|
Tennis |
|
|
|
|
|
|
|
|
|
|
|
|
|
Skiing
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Weight Lifting |
|
|
|
|
|
|
|
|
|
|
|
|
|
Housework |
|
|
|
|
|
|
|
|
|
|
|
|
|
Washing the Car |
|
|
|
|
|
|
|
|
|
|
|
|
|
Washing the Dog |
|
|
|
|
|
|
|
|
|
|
|
|
|
Cooking |
|
|
|
|
|
|
|
|
|
|
|
|
|
Laundry |
|
|
|
|
|
|
|
|
|
|
|
|
|
Home Exercise Equipment |
|
|
|
|
|
|
|
|
|
|
|
|
|
Computer Work |
|
|
|
|
|
|
|
|
|
|
|
|
|
Other: |
|
|
|
|
|
|
|
|
|
|
|
|
Activities and their Duration
List the amount of time you spend on the activities listed below.
Activity |
N
e
v
e
r |
M
i
n
u
t
e
s |
H
o
u
r
s |
W
e
e
k
l
y |
D
a
i
l
y |
|
Swimming |
|
|
|
|
|
|
Running |
|
|
|
|
|
|
Walking |
|
|
|
|
|
|
Dancing |
|
|
|
|
|
|
Biking |
|
|
|
|
|
|
Gardening |
|
|
|
|
|
|
Golfing |
|
|
|
|
|
|
Tennis |
|
|
|
|
|
|
Skiing
|
|
|
|
|
|
|
Weight Lifting |
|
|
|
|
|
|
Housework |
|
|
|
|
|
|
Washing the Car |
|
|
|
|
|
|
Washing the Dog |
|
|
|
|
|
|
Cooking |
|
|
|
|
|
|
Laundry |
|
|
|
|
|
|
Home Exercise Equipment |
|
|
|
|
|
|
Computer Work |
|
|
|
|
|
|
Other: |
|
|
|
|
|
