History Form
Note: Complete and sign this form (with your parents if younger than 18) before your appointment.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(A sum of ≥3 is considered positive on either subscale [questions 1 and 2, or questions 3 and 4] for screening purposes.)
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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