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Medical Symptoms Questionnaire
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Head
Headaches
*
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
Never or Almost Never Happens
0
1
2
3
4
Frequently happens, Effect is Severe
Faintness
*
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
0
1
2
3
4
Dizziness/Vertigo
*
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
0
1
2
3
4
Insomnia
*
0; Never or Almost never, 1; Occasionally, Effect NOT Severe, 2; Occasionally, Effect IS SEVERE, 3; Frequently, Effect NOT Severe, 4; Frequently, Severe Effect
0
1
2
3
4
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