Box 3 deals with symptoms of eating and the gastrointestinal tract.

• Sum the scores symptoms that apply.
• Record the value in the box.
• Click for a larger view.

Box 4 deals with activity level

• This one is additive. Check all that apply and put the combined score in the box.
• Click for a larger view.

Now comes your part. Go to the second page of the form and you'll see the parts filled in by the therapist or doctor.