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CHIPS |
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Mark the number for each statement that best describes HOW MUCH THAT PROBLEM HAS BOTHERED OR DISTRESSED YOU DURING THAT PAST TWO WEEKS INCLUDING TODAY. Mark only one number for each item. At one extreme, 0 means that you have not been bothered by the problem. At the other extreme, 4 means that the problem has been an extreme bother. |
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HOW MUCH WERE YOU BOTHERED BY: |
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1. Sleep problems (can't fall asleep, wake up in middle of night or early in morning) |
0 |
1 |
2 |
3 |
4 |
|
2. Weight change (gain or loss of 5 libs. or more) |
0 |
1 |
2 |
3 |
4 |
|
3. Back pain |
0 |
1 |
2 |
3 |
4 |
|
4. Constipation |
0 |
1 |
2 |
3 |
4 |
|
5. Dizziness |
0 |
1 |
2 |
3 |
4 |
|
6. Diarrhea |
0 |
1 |
2 |
3 |
4 |
|
7. Faintness |
0 |
1 |
2 |
3 |
4 |
|
8. Constant fatigue |
0 |
1 |
2 |
3 |
4 |
|
9. Headache |
0 |
1 |
2 |
3 |
4 |
|
10. Migraine headache |
0 |
1 |
2 |
3 |
4 |
|
11. Nausea and/or vomiting |
0 |
1 |
2 |
3 |
4 |
|
12. Acid stomach or indigestion |
0 |
1 |
2 |
3 |
4 |
|
13. Stomach pain (e.g., cramps) |
0 |
1 |
2 |
3 |
4 |
|
14. Hot or cold spells |
0 |
1 |
2 |
3 |
4 |
|
15. Hands trembling |
0 |
1 |
2 |
3 |
4 |
|
16. Heart pounding or racing |
0 |
1 |
2 |
3 |
4 |
|
17. Poor appetite |
0 |
1 |
2 |
3 |
4 |
|
18. Shortness of breath when not exercising or working hard |
0 |
1 |
2 |
3 |
4 |
|
19. Numbness or tingling in parts of your body |
0 |
1 |
2 |
3 |
4 |
|
20. Felt weak all over |
0 |
1 |
2 |
3 |
4 |
|
21. Pains in heart or chest |
0 |
1 |
2 |
3 |
4 |
|
22. Feeling low in energy |
0 |
1 |
2 |
3 |
4 |
|
23. Stuffy head or nose |
0 |
1 |
2 |
3 |
4 |
|
24. Blurred vision |
0 |
1 |
2 |
3 |
4 |
|
25. Muscle tension or soreness |
0 |
1 |
2 |
3 |
4 |
|
26. Muscle cramps |
0 |
1 |
2 |
3 |
4 |
|
27. Severe aches and pains |
0 |
1 |
2 |
3 |
4 |
|
28. Acne |
0 |
1 |
2 |
3 |
4 |
|
29. Bruises |
0 |
1 |
2 |
3 |
4 |
|
30. Nosebleed |
0 |
1 |
2 |
3 |
4 |
|
31. Pulled (strained) muscles |
0 |
1 |
2 |
3 |
4 |
|
32. Pulled (strained) ligaments |
0 |
1 |
2 |
3 |
4 |
|
33. Cold or cough |
0 |
1 |
2 |
3 |
4 |