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* 1. FIRE/HEART ELEMENT Have you experienced any of these symptoms in the last 3 months? (Check all that apply)

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* 2. EARTH/SPLEEN ELEMENT - Have you experienced any of these symptoms in the last 3 months? (Check all that apply)

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* 3. METAL/LUNG & LARGE INTESTINE ELEMENT - Have you experienced any of these symptoms in the last 3 months? (Check all that apply)

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* 4. WATER/KIDNEY & BLADDER ELEMENT - Have you experienced any of these symptoms in the last 3 months? (Check all that apply)

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* 5. WOOD/LIVER & GALL BLADDER ELEMENT - Have you experienced any of these symptoms in the last 3 months? (Check all that apply)

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