Instructions for this Toxicity Questionnaire
Read the following questions and rate them based on how you have been feeling in the past 30 days.
0 (or leave blank) = No, or never, or almost never occurs
1 = Occasionally occurs, effect is not severe
2 = Occasionally occurs, effect is severe
3 = Frequently occurs, effect is not severe
This questionnaire was developed by Systemic Formulas, Inc. The questionnaire is not intended to be used to diagnose any disease or as a basis for prescribing for any disease. It is solely for clinician insight and patient self-knowledge. If you are interested in learning more, or would like to have access to additional questionnaires, schedule a complementary consultation today.