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 sever.
YEAR:
________
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Jan. |
Feb. |
Mar. |
Apr. |
May |
June |
July |
Aug. |
Sept. |
Oct. |
Nov. |
Dec. |
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SYMPTOMS: |
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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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Vertigo
(dizziness) |
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Facial
pain |
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Facial
weakness |
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