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Pre-Appointment Questionnaire 

Birthday
Day
Month
Year

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?
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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