Toxicity Questionnaire

Section I: Symptoms

Rate each of the following based upon your health profile for the past 90 days.

0 Rarely or Never Experience the Symptom
1 Occasionally Experience the Symptom, Effect is Not Severe
2 Occasionally Experience the Symptom, Effect is Severe
3 Frequently Experience the Symptom, Effect is Not Severe
4 Frequently Experience the Symptom, Effect is Severe

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