SYMPTOM SURVEY FORM

_ Irritability _ Ears Ringing _ Back Pain _ Difficulty Sleeping_ Fatigue _ Jaw Problems _ Chest Pain _ Arm/ Shoulder Pain_ Leg Pain _ Back Stiffness _ Blurred Vision _Numb Hand/ Fingers _ Tension _ Low Back Pain _ Neck Stiffness _Shortness of Breath _ Nausea _ Buzzing in Ear _ … ................
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