Pre- appointment questionnaire | Cambridge Complete P

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Pre-Appointment Questionnaire

First name

Last name

Birthday

Day

Month

Year

Email

Phone

Please provide a brief description of your symptoms

Please include: -location of problem?

-how long you have had this problem?

-is it getting worse, better or staying the same?

What type of symptoms are you getting?

Pain

Ache

Weakness

Abnormal sensation (e.g. numbness, pins and needles, tingling)

Other

Does your problem cause you significant sleep loss every night?

Yes

No

Do you have a history of cancer?

Yes

No

Are you currently pregnant?

Yes

No

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