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Health Assessment

  • Date Format: MM slash DD slash YYYY
  • This questionnaire is a valuable tool for us to gain information about your current symptoms and health concerns. Should you wish to save your completed answers to the questionnaire and return at a later date to finish the questionnaire, please select the save button at the bottom of the page. Please note that after two weeks your saved questionnaire will no longer be available and you will have to complete the questionnaire again in its entirety. Please complete your details below to begin the questionnaire.
  • 0 = never or almost never; 1 = sometimes; 2 = often, not severe; 3 = not often, severe; 4 = often, severe
  • Please enter a number from 0 to 4.
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  • Additional Questions for Women

  • What have you used, for how long, and what age(s)?