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1
Patient ID number
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2
Caregiver ID number
*
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3
Date
*
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Date
שנה
חודש
יום
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4
Treatment No
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This field is required.
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5
How would you rate the change in your symptoms since your last treatment session?
(1 the lowest to 10 the highest. If there is no change select "no change")
אנא בחר
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10
אנא בחר
אנא בחר
1
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10
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6
Have you experienced a reduction in the frequency of your symptoms since your last treatment session?
אנא בחר
Yes
No
אנא בחר
אנא בחר
Yes
No
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7
Have you experienced a reduction in the severity of your symptoms since your last treatment session?
אנא בחר
Yes
No
אנא בחר
אנא בחר
Yes
No
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8
Does the symptoms have an effect on:
(1 the lowest to 10 the highest. If not applicable, select "not applicable")
Please Select
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10
not applicable
Please Select
Please Select
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10
not applicable
Dailyactivities
Please Select
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not applicable
Please Select
Please Select
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not applicable
Rest
Please Select
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not applicable
Please Select
Please Select
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not applicable
Ability at Work
Please Select
1
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10
not applicable
Please Select
Please Select
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not applicable
Sleep
Please Select
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not applicable
Please Select
Please Select
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not applicable
Apatite
Please Select
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not applicable
Please Select
Please Select
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not applicable
General Well Being
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9
How satisfied are you with the results of your treatment session today?
On a scale of 1 to 10, with 1 being very dissatisfied and 10 being very satisfied
אנא בחר
1
2
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9
10
אנא בחר
אנא בחר
1
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10
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10
Additional Comments
Please share any additional comments, feedback, or concerns you have about your treatment session or your progress in recovery
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