Medical Symptom Questionnaire

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Rate each of the following symptoms based upon your typical health profile for the past 14 days.
0 – Never or almost never have the symptom
1– Occasionally have it, effect is not severe
2 – Occasionally have it, effect is severe
3– Frequently have it, effect is not sever
4– Frequently have it, effect is severe
* Required

Email *

Patient's Name *

Age *

Enter your Age in Years

Height *

Your Height in Feet and Inches

Weight in Kgs *

Blood Group

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