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MEDICAL SYMPTOMS QUESTIONNAIRE

Rate each of the following symptoms based upon your typical health profile for the past 30 days.

Point Scale:

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 severe 
4 - Frequently have it, effect is severe

Head
Eyes
Ears
Nose
Mouth/Throat
Skin
Heart
Lungs
Digestive Tract
Joints/Muscle
Weight
Energy/Activity
Mind
Emotions
Other
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