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* 1. Check off any of the following symptoms you have experienced in the past 6 months. Mark "Y" for yes, and leave a comment if necessary. A blank response will reflect "No Issues with this item"

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* 2. Which of the above is worst? 

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* 3. How long have you experienced this? 

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* 4. When is it at its worst and how does it feel?

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* 5. Does this cause any of the following? Y or N

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* 6. Does this affect your work? Y or N

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* 7. Does this affect your life? Y or N

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* 8. 8. Please leave your name and email. We will not share your information with others. We may add your email to our monthly newsletter. You will have the option to opt-out if you do not wish to receive it. 

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