Adverse Effects Questionnaire Survey

Thanks for coming into our lab and we hope that you are feeling great. We are sending this questionnaire to monitor any side effects that could have occurred in the past 24 hours. Please contact your primary care physician as soon as possible!

	Very Mild	Mild	Moderate	Severe	Very Severe	N/A
Itching	Itching Very Mild	Itching Mild	Itching Moderate	Itching Severe	Itching Very Severe	Itching N/A
Burning	Burning Very Mild	Burning Mild	Burning Moderate	Burning Severe	Burning Very Severe	Burning N/A
Tingling	Tingling Very Mild	Tingling Mild	Tingling Moderate	Tingling Severe	Tingling Very Severe	Tingling N/A
Headache	Headache Very Mild	Headache Mild	Headache Moderate	Headache Severe	Headache Very Severe	Headache N/A
Fatigue	Fatigue Very Mild	Fatigue Mild	Fatigue Moderate	Fatigue Severe	Fatigue Very Severe	Fatigue N/A
Sudden mood change	Sudden mood change Very Mild	Sudden mood change Mild	Sudden mood change Moderate	Sudden mood change Severe	Sudden mood change Very Severe	Sudden mood change N/A
Difficulty concentrating	Difficulty concentrating Very Mild	Difficulty concentrating Mild	Difficulty concentrating Moderate	Difficulty concentrating Severe	Difficulty concentrating Very Severe	Difficulty concentrating N/A
Change in visual perception	Change in visual perception Very Mild	Change in visual perception Mild	Change in visual perception Moderate	Change in visual perception Severe	Change in visual perception Very Severe	Change in visual perception N/A
Unpleasant sensations	Unpleasant sensations Very Mild	Unpleasant sensations Mild	Unpleasant sensations Moderate	Unpleasant sensations Severe	Unpleasant sensations Very Severe	Unpleasant sensations N/A
Nausea	Nausea Very Mild	Nausea Mild	Nausea Moderate	Nausea Severe	Nausea Very Severe	Nausea N/A
Drowsiness	Drowsiness Very Mild	Drowsiness Mild	Drowsiness Moderate	Drowsiness Severe	Drowsiness Very Severe	Drowsiness N/A
Pain	Pain Very Mild	Pain Mild	Pain Moderate	Pain Severe	Pain Very Severe	Pain N/A
Nervousness	Nervousness Very Mild	Nervousness Mild	Nervousness Moderate	Nervousness Severe	Nervousness Very Severe	Nervousness N/A

Very Mild

Mild

Moderate

Severe

Very Severe

N/A

Itching

Itching Very Mild

Itching Mild

Itching Moderate

Itching Severe

Itching Very Severe

Itching N/A

Burning

Burning Very Mild

Burning Mild

Burning Moderate

Burning Severe

Burning Very Severe

Burning N/A

Tingling

Tingling Very Mild

Tingling Mild

Tingling Moderate

Tingling Severe

Tingling Very Severe

Tingling N/A

Headache

Headache Very Mild

Headache Mild

Headache Moderate

Headache Severe

Headache Very Severe

Headache N/A

Fatigue

Fatigue Very Mild

Fatigue Mild

Fatigue Moderate

Fatigue Severe

Fatigue Very Severe

Fatigue N/A

Sudden mood change

Sudden mood change Very Mild

Sudden mood change Mild

Sudden mood change Moderate

Sudden mood change Severe

Sudden mood change Very Severe

Sudden mood change N/A

Difficulty concentrating

Difficulty concentrating Very Mild

Difficulty concentrating Mild

Difficulty concentrating Moderate

Difficulty concentrating Severe

Difficulty concentrating Very Severe

Difficulty concentrating N/A

Change in visual perception

Change in visual perception Very Mild

Change in visual perception Mild

Change in visual perception Moderate

Change in visual perception Severe

Change in visual perception Very Severe

Change in visual perception N/A

Unpleasant sensations

Unpleasant sensations Very Mild

Unpleasant sensations Mild

Unpleasant sensations Moderate

Unpleasant sensations Severe

Unpleasant sensations Very Severe

Unpleasant sensations N/A

Nausea

Nausea Very Mild

Nausea Mild

Nausea Moderate

Nausea Severe

Nausea Very Severe

Nausea N/A

Drowsiness

Drowsiness Very Mild

Drowsiness Mild

Drowsiness Moderate

Drowsiness Severe

Drowsiness Very Severe

Drowsiness N/A

Pain

Pain Very Mild

Pain Mild

Pain Moderate

Pain Severe

Pain Very Severe

Pain N/A

Nervousness

Nervousness Very Mild

Nervousness Mild

Nervousness Moderate

Nervousness Severe

Nervousness Very Severe

Nervousness N/A

Adverse Effects Questionnaire

Question Title

* 1. When was your lab session?

Question Title

* 2. Do you feel any of the following?

Question Title

* 3. Any other adverse effects not listed above or any concerns:
Please describe what sensations you feel specifically in the space below. These sensations could relate to visual, hearing, touch, etc.

Adverse Effects Questionnaire

Question Title

* 1. When was your lab session?

Question Title

* 2. Do you feel any of the following?

Question Title

* 3. Any other adverse effects not listed above or any concerns:Please describe what sensations you feel specifically in the space below. These sensations could relate to visual, hearing, touch, etc.

* 3. Any other adverse effects not listed above or any concerns:
Please describe what sensations you feel specifically in the space below. These sensations could relate to visual, hearing, touch, etc.