Questionnaire

Point Scale

  • 0Never or almost never have the symptom
  • 1Occasionally have it, effect is not severe
  • 2Occasionally have it, effect is severe
  • 3Frequently have it, effect is not severe
  • 4Frequently have it, effect is severe
Progress

[i4w_actionset actid=’346′ tagid=’-110,-112,-114′ autorun=1]
[i4w_survey svy_type=’radio’ redir=’/msq/part-2/’ required=’yes’ svy_btn=’CONTINUE TO PART 2′]

svy_question:Headaches
svy_answer1:0
svy_answer2:1
svy_answer3:2
svy_answer4:3
svy_answer5:4
svy_action2:A212,A234
svy_action3:A214,A232
svy_action4:A216,A230
svy_action5:A218,A228

svy_question:Faintness
svy_answer6:0
svy_answer7:1
svy_answer8:2
svy_answer9:3
svy_answer10:4
svy_action7:A212,A234
svy_action8:A214,A232
svy_action9:A216,A230
svy_action10:A218,A228

svy_question:Dizziness
svy_answer11:0
svy_answer12:1
svy_answer13:2
svy_answer14:3
svy_answer15:4
svy_action12:A212,A234
svy_action13:A214,A232
svy_action14:A216,A230
svy_action15:A218,A228

svy_question:Insomnia
svy_answer16:0
svy_answer17:1
svy_answer18:2
svy_answer19:3
svy_answer20:4
svy_action17:A212,A234
svy_action18:A214,A232
svy_action19:A216,A230
svy_action20:A218,A228

svy_question:Watery or Itchy Eyes
svy_answer21:0
svy_answer22:1
svy_answer23:2
svy_answer24:3
svy_answer25:4
svy_action22:A212,A242
svy_action23:A214,A240
svy_action24:A216,A238
svy_action25:A218,A236

svy_question:Swollen Reddened Eyes or Sticky Eyelids
svy_answer26:0
svy_answer27:1
svy_answer28:2
svy_answer29:3
svy_answer30:4
svy_action27:A212,A242
svy_action28:A214,A240
svy_action29:A216,A238
svy_action30:A218,A236

svy_question:Bags or Dark Circles Under Eyes
svy_answer31:0
svy_answer32:1
svy_answer33:2
svy_answer34:3
svy_answer35:4
svy_action32:A212,A242
svy_action33:A214,A240
svy_action34:A216,A238
svy_action35:A218,A236

svy_question:Blurred or Tunnel Vision
svy_answer36:0
svy_answer37:1
svy_answer38:2
svy_answer39:3
svy_answer40:4
svy_action37:A212,A242
svy_action38:A214,A240
svy_action39:A216,A238
svy_action40:A218,A236

svy_question:Itchy Ears
svy_answer41:0
svy_answer42:1
svy_answer43:2
svy_answer44:3
svy_answer45:4
svy_action42:A212,A250
svy_action43:A214,A248
svy_action44:A216,A246
svy_action45:A218,A244

svy_question:Earaches or Ear Infections
svy_answer46:0
svy_answer47:1
svy_answer48:2
svy_answer49:3
svy_answer50:4
svy_action47:A212,A250
svy_action48:A214,A248
svy_action49:A216,A246
svy_action50:A218,A244

svy_question:Drainage From Ear
svy_answer51:0
svy_answer52:1
svy_answer53:2
svy_answer54:3
svy_answer55:4
svy_action52:A212,A250
svy_action53:A214,A248
svy_action54:A216,A246
svy_action55:A218,A244

svy_question:Ringing in Ears or Hearing Loss
svy_answer56:0
svy_answer57:1
svy_answer58:2
svy_answer59:3
svy_answer60:4
svy_action57:A212,A250
svy_action58:A214,A248
svy_action59:A216,A246
svy_action60:A218,A244

svy_question:Chronic Coughing
svy_answer61:0
svy_answer62:1
svy_answer63:2
svy_answer64:3
svy_answer65:4
svy_action62:A212,A258
svy_action63:A214,A256
svy_action64:A216,A254
svy_action65:A218,A252

svy_question:Gagging or Frequent Need To Clear Throat
svy_answer66:0
svy_answer67:1
svy_answer68:2
svy_answer69:3
svy_answer70:4
svy_action67:A212,A258
svy_action68:A214,A256
svy_action69:A216,A254
svy_action70:A218,A252

svy_question:Sore Throat, Hoarsement or Loss of Voice
svy_answer71:0
svy_answer72:1
svy_answer73:2
svy_answer74:3
svy_answer75:4
svy_action72:A212,A258
svy_action73:A214,A256
svy_action74:A216,A254
svy_action75:A218,A252

svy_question:Swollen or Discolored Tongue, Gums, or Lips
svy_answer76:0
svy_answer77:1
svy_answer78:2
svy_answer79:3
svy_answer80:4
svy_action77:A212,A258
svy_action78:A214,A256
svy_action79:A216,A254
svy_action80:A218,A252

svy_question:Canker Sores
svy_answer81:0
svy_answer82:1
svy_answer83:2
svy_answer84:3
svy_answer85:4
svy_action82:A212,A258
svy_action83:A214,A256
svy_action84:A216,A254
svy_action85:A218,A252

[/i4w_survey]

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