In the last 7 days...

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* 1. Have you tried our pain-relief formula β-Relieved?
(If yes, tell us for how long).

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* 2. In the last week, on average, how intense was your pain at its worst? Use the scale from 1 to 5, where 1 is "had no pain" 2 is "mild" 3 is "moderate" 4 is "severe" and 5 is "very much."

1 Had No Pain 5 Very Severe
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 3. In the last week, how much has pain interfered with your daily activities? Use the scale from 1 to 5, where 1 is "not at all" 2 is "a little bit" 3 is "somewhat" 4 is "quite a bit"  and 5 is "very much."

1 Not at all 5 Very Much
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 4. Contact Info

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* 5. Physician's Name

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