*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
Draw
Type
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*
*
constant
*
intermittent
*
mild
*
moderate
*
severe
*
*
symptoms up w/activity
*
symptoms down w/activity
*
getting worse
*
getting better
*
no change
*
*
*
*
*
sleep
*
washing
*
dressing
*
fitness
*
mild
*
moderate
*
severe
*
*
constant
*
intermittent
*
symptoms up w/activity
*
symptoms down w/activity
*
*
getting worse
*
getting better
*
no change
*
*
*
*
mild
*
moderate
*
severe
*
constant
*
intermittent
*
symptoms up w/activity
*
symptoms down w/activity
*
*
getting worse
*
getting better
*
no change
*
*
*
Yes
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No
*
*
*
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Current
*
Past
*
Draw
Type
Upload
Choose your signature image
*
*
Draw
Type
Upload
Choose your signature image
*
*
Draw
Type
Upload
Choose your signature image
*
*
*
Draw
Type
Upload
Choose your signature image
*
*
Draw
Type
Upload
Choose your signature image
*
*
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