Please describe your chief complaint today:
(eg Lower back pain, Pain in my left leg, Headaches etc)
Please select any of the following symtoms that best describes your pain or other sensation:
Please select to show how bad your usual pain is:
I have no pain
worst possible pain
In the past month have you suffered from any of the following?
Do you or have you suffered from any of the following illnesses?
Please advise if any of the above information changes during the course of treatment
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