Pulse:
Blood Pressure:
INSTRUCTIONS: Fill in only the circles which apply to you. Leave circles blank if they don’t apply to you! Some questions will repeat.
1 - Mild, 2 - Moderate, 3 - Severe
--------------------------------------------- GROUP 01 ---------------------------------------------
--------------------------------------------- GROUP 02 ---------------------------------------------
--------------------------------------------- GROUP 03 ---------------------------------------------
--------------------------------------------- GROUP 04 ---------------------------------------------
--------------------------------------------- GROUP 05 ---------------------------------------------
--------------------------------------------- GROUP 06 ---------------------------------------------
--------------------------------------------- GROUP 07A---------------------------------------------
--------------------------------------------- GROUP 07B---------------------------------------------
--------------------------------------------- GROUP 07C---------------------------------------------
--------------------------------------------- GROUP 07D---------------------------------------------
--------------------------------------------- GROUP 07E---------------------------------------------
--------------------------------------------- GROUP 07F---------------------------------------------
--------------------------------------------- GROUP 08---------------------------------------------
--------------------------------------------- FEMALE ONLY-------------------------------------
--------------------------------------------- MALE ONLY-------------------------------------
IMPORTANT: List the five main complaints you have in the order of their importance.
(Your digital signature (full name) is as legally binding as a physical signature.)