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English (US)
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Name
*
First Name
Last Name
Email
*
example@example.com
DATE
*
/
Month
/
Day
Year
Date
Please mark the area of injury or discomfort on the chart below with an x or circle the area.
*
Check the pain description that matches your symptoms the most from the list below
*
Numbness
Aching
Burning
Pins/Needles
Stabbing
Shooting
Other
What percent of the day do your symptoms affect you?
*
Total Hours
Please rate your current pain level by selecting it on the scale below with "0" meaning no pain and "10" meaning unbearable pain.
*
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Please list any pre existing medical conditions you are currently diagnosed with
Please list any medications you are currently taking (prescription, over the counter, supplements)
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