PATIENT INFORMATION QUESTIONNAIRE - REX Health
How do the following factors affect your pain? (check one blank per number) Better Worse No effect Better Worse No effect. 1. Heat 6. Climate 2. Cold 7. Fatigue 3. Lying down 8. Coughing 4. Sitting 9. Massage 5. Walking 10. Alcohol Which of the following activities are affected by your pain? ................
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