MSNQ Informant

Background information

About You:

City State Country

About the Patient:

    Day Month Year
The following questions ask about problems that the patient may experience. We want you to rate how often these problems occur AND how severe they are. Base your responses on his/her behavior over the last three months.

Please check the appropriate button.

very often, very disruptive
quite often, interferes w/ life
occasionally, seldom a problem
very rarely, no problem
never, does not occur