Instructions: Place a (√) check in the box to the right of each of the 15 symptom clusters to indicate
how much this type of feeling has been bothering you in the past several days. Make sure you answer
all the questions. If you feel unsure about any, put down your best guess. If you would like a weekly
record of you progress, record your answers on the separate “Answer Sheet” instead of filling in the
spaces to the right.