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Patient Follow Up Questionnaire
Form completion time: under 5 minutes.
Full name
Which post-treatment interval are you submitting this questionnaire for?
3 month
6 month
9 month
12 month
15 month
18 month
21 month
24 month
Subjective Memory
Please indicate your ability to recall information as of today.
1 = poor
10 = excellent
How would you rate your memory?
1
2
3
4
5
6
7
8
9
10
How is your memory of recent events? (today)
1
2
3
4
5
6
7
8
9
10
How is your memory of past events? (10 years)
1
2
3
4
5
6
7
8
9
10
Overall Health
Please indicate a number that best identifies your response toward each statement.
1 = poor
10 = excellent
Physical fitness
1
2
3
4
5
6
7
8
9
10
Flexibility
1
2
3
4
5
6
7
8
9
10
Energy level
1
2
3
4
5
6
7
8
9
10
Balance
1
2
3
4
5
6
7
8
9
10
Coordination
1
2
3
4
5
6
7
8
9
10
Reaction time
1
2
3
4
5
6
7
8
9
10
Strength
1
2
3
4
5
6
7
8
9
10
Stamina
1
2
3
4
5
6
7
8
9
10
Vision
1
2
3
4
5
6
7
8
9
10
Hearing
1
2
3
4
5
6
7
8
9
10
Libido
1
2
3
4
5
6
7
8
9
10
Sexual function
1
2
3
4
5
6
7
8
9
10
Quality of sleep
1
2
3
4
5
6
7
8
9
10
Ability to concentrate
1
2
3
4
5
6
7
8
9
10
Ability to make decisions
1
2
3
4
5
6
7
8
9
10
Stress level
1
2
3
4
5
6
7
8
9
10
Confidence
1
2
3
4
5
6
7
8
9
10
Motivation
1
2
3
4
5
6
7
8
9
10
Symptom management
1
2
3
4
5
6
7
8
9
10
Daily pain level
1 =Extreme pain
10 = No pain
1
2
3
4
5
6
7
8
9
10
Thickness of hair
1
2
3
4
5
6
7
8
9
10
Please explain any changes or improvements you have noticed
Thank you! Your submission has been received!
Oops! Please make sure to fill out every question.
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