HOW OFTEN HAVE YOU DURING RECENT MONTHS EXPERIENCED ANY OF THE FOLLOWING AND FOR HOW MANY YEARS HAVE YOU HAD THESE SYMPTOMS? 1 2 3 Often 4 Very Number of – – – – Seldom or often years never experienced 14. Dropping things unintentionally 1 2 3 4 15. Weakness of your arms and feet 1 2 3 4 16. Decreased sensation in arms and 1 2 3 4 legs 17. Numbness or heaviness in your arms 1 2 3 4 or legs 18. Tingling in your arms or legs 1 2 3 4 19. Problems with balance 1 2 3 4 20. Changes in sense of smell or taste 1 2 3 4 21. Decreased sensation on your face 1 2 3 4 22. Difficulties controlling your hand 1 2 3 4 movements (i.e. how often do you notice your hands are more clumsy?) 23. Slowness in carrying out your daily 1 2 3 4 activities 24. Trembling of hands 1 2 3 4 25. Headache 1 2 3 4 26. Sweating for no obvious reason 1 2 3 4 27. Nausea (i.e. do you feel sick in your 1 2 3 4 stomach?) 1 2 3 Often 4 Very Number of – – – – Seldom or often years never experienced 28. Stomach pains 1 2 3 4 29. Dizziness 1 2 3 4 30. Shortness of breath without physical 1 2 3 4 exertion 31. Heart fluttering (palpitations) 1 2 3 4
HOW OFTEN HAVE YOU DURING RECENT MONTHS EXPERIENCED ANY OF THE FOLLOWING AND FOR HOW MANY YEARS HAVE YOU HAD THESE SYMPTOMS? 1 – Seldom or never 2 – 3 – Often 4 – Very often Number of years experienced 14. Dropping things unintentionally 1 2 3 4 15. Weakness of your arms and feet 1 2 3 4 16. Decreased sensation in arms and legs 1 2 3 4 17. Numbness or heaviness in your arms or legs 1 2 3 4 18. Tingling in your arms or legs 1 2 3 4 19. Problems with balance 1 2 3 4 20. Changes in sense of smell or taste 1 2 3 4 21. Decreased sensation on your face 1 2 3 4 22. Difficulties controlling your hand movements (i.e. how often do you notice your hands are more clumsy?) 1 2 3 4 23. Slowness in carrying out your daily activities 1 2 3 4 24. Trembling of hands 1 2 3 4 25. Headache 1 2 3 4 26. Sweating for no obvious reason 1 2 3 4 27. Nausea (i.e. do you feel sick in your stomach?) 1 2 3 4 1 – Seldom or never 2 – 3 – Often 4 – Very often Number of years experienced 28. Stomach pains 1 2 3 4 29. Dizziness 1 2 3 4 30. Shortness of breath without physical exertion 1 2 3 4 31. Heart fluttering (palpitations) 1 2 3 4
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