Required fields are marked with an asterisk *.

The questions below are to help your doctor have a better understanding of your symptoms and how they affect your daily function. Please answer each question by marking the box that best describes your symptom over the past few weeks. Please do not leave any questions blank and mark only 1 answer each.

I have headaches *
I have neck pain *
I have arm pain in my *
I experience pain in my arm(s) *
I have back pain *
I have dizziness or feel faint *
I have ringing in my *
I experience the ringing in my ear(s) *
I have trouble swallowing *
I have trouble reading due to blurred vision *
I have trouble with my balance while walking *
My symptoms prevent me from participating in activities I enjoy *
My symptoms prevent me from exercising regularly *
I need help to bathe and dress *
I need someone else/cane/walker to help me walk *
I feel sad or depressed *
I feel angry *
I need help to take care of my family *
I have difficulty concentrating, thinking and problem solving *
I have difficulty reading and understanding letters/books or newspapers *
I have difficulty speaking clearly *
I cannot walk more than 10 minutes without stopping to rest *
I need to lie down during the day to rest *
I am working shorter or limited amount of hours due to my symptoms *
I have difficulty sleeping at night *
I feel my heart racing or have palpitations *
I feel generally tired or fatigued *
I need assistance with shopping *
I need someone else to drive me to the store/appointments *
I feel irritable *
I need help to do housework (laundry, vacuuming, and dusting) *
I have difficulty holding objects in my hands *
I feel short of breath or have difficulty breathing *
I am confused and forget what I am doing *
I have trouble finding the right words to communicate my needs *
I lose control of my bowel/bladder *
I have trouble with fine motor tasks such as buttoning buttons *
Food does not taste normal *
I choke when I try to swallow liquids *
I have been told that I snore loudly at night *
I have been told that I stop breathing at night or while lying flat *
I feel nauseated or sick to my stomach *
I feel like the room is spinning around me *
My face feels numb *
I have double vision *
Bright lights hurt my eyes *
I have head pain when I cough/sneeze or strain *
I have head pain when I bend forward or lean over *
I have head pain when I look up at the sky or the top shelf *
My tongue is numb or tingly *
I get a headache when I stand up after lying down *
I have hiccups *
My eyes twitch or jump *
I have arm numbness in my *
I experience arm numbness *
I have heartburn or indigestion *
I need to take pain medication to get through the day *
I have generalized body pain (all over my body) *
I have constipation (difficulty or pain having a bowel movement) *
Overall, I feel unhappy and/or frustrated about my health *
With regard to my Chiari symptoms, and their impact on my life *
I would rate the quality of my life *

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