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Symptom Survey

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Patient Information

MM slash DD slash YYYY

Symptom Discomfort Scale

Please rate the following symptoms from 0 to 10, where 0 indicates no discomfort and 10 indicates the worst discomfort imaginable.
If the symptom is not occurring, please select N/A.

Symptom Frequency Scale

Please rate the following symptoms according to the frequency with which they occur, where 0 indicates never and 10 indicates constantly.

Pain Locations

Edit each of the following images to show exactly where your pain is and how it feels.
Click the pencil to edit each image.