Indicate which of the below you have experienced in the last 1-2 months 1 = Never; 2 = Rarely; 3 = Occasionally; 4 = Frequently; 5 = Constantly
Eyes / Ears / Nose / Throat / Respiratory
Muscular / Skeletal
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.
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