Too shy to ask the Dr. Fill in. Print and give to him rather than you explianing your symptoms

This questionnaire is for you to take to your doctor for them to make a better assessment about your condition. We do not ask for any personal information, this is between you and your doctor. If you wish to learn more about what we do please visit www.candgmedicare.com your medical specialist team.

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* 1. What sex are you?

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* 2. Where is the problem area

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* 3. I have pain if...

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* 4. The symptoms I have..

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* 5. Have you had surgery within the past year?

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* 6. Within the last 10 years I have been diagnosed with

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* 7. Within the last 10 years I have been treated for

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* 8. Have you used any medications, (oral or topical) for your condition? Write the names of the medications.

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* 9. I have given birth

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* 10. Pregnancy

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