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1
Patient ID number
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2
Caregiver ID number
*
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3
Date
*
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Date
שנה
חודש
יום
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4
Treatment No
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This field is required.
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5
How would you rate the change in your symptoms since starting treatment?
(1 the lowest to 10 the highest. If there is no change select "no change")
אנא בחר
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אנא בחר
אנא בחר
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6
Have you experienced a reduction in the frequency of your symptoms starting treatment?
אנא בחר
Yes
No
אנא בחר
אנא בחר
Yes
No
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7
Have you experienced a reduction in the severity of your symptoms since starting treatment?
אנא בחר
Yes
No
אנא בחר
אנא בחר
Yes
No
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8
Are the symptoms affecting:
(1 the lowest to 10 the highest. If not applicable, select "not applicable")
Please Select
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not applicable
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not applicable
Dailyactivities
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not applicable
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not applicable
Rest
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not applicable
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Ability at Work
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not applicable
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Sleep
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not applicable
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Apatite
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not applicable
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Please Select
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General Well Being
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9
How would you rate your overall emotional well-being at present?
(1 the lowest to 10 the highest. If there is no change select "no change")
אנא בחר
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אנא בחר
אנא בחר
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10
How satisfied are you with the results of your treatment journey?
On a scale of 1 to 10, with 1 being very dissatisfied and 10 being very satisfied
אנא בחר
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אנא בחר
אנא בחר
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11
Having received treatment, can you say that the symptoms that led you to seek treatment have been alleviated?
On a scale of 1 to 10, with 1 not alleviated and 10 have been alleviated.
אנא בחר
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אנא בחר
אנא בחר
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12
Would you recommend the treatments and interventions you received during your recovery journey to others with similar conditions?
yes
No
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13
Additional Comments
Please share any additional comments, reflections, or insights you have about your recovery journey, including any challenges, successes, or lessons learned.
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