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Headache
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Neck Pain
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Shoulder Pain
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Mid-Back Pain
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Elbow Pain
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Wrist Pain
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Low Back Pain
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Upper Leg Pain
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Knee Pain
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Lower Leg Pain
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Ankle Pain
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Foot Pain
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Pain scale (0 no pain 5 moderate 10 unbearable)
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What makes it worse? (pick one or more)
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What kind of pain is it? (Pick one or more)
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What makes it better? (Pick one or more)
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When is it worse? (pick one)
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How often do you feel your pain? (pick one)
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Does it radiate? (pick a side then location)
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Anything you like to add? (Please be brief)
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Review of System
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Please read the instruction and turn on the switch
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Instruction
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Const. (Health in General)
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Other
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Ears, Nose, Mouth & Throat
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Other
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C-V (Heart & Blood Vessels)
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Other
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Resp. (Lungs & Breathing)
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Other
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GI (Stomach & Intestines)
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Other
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MS (Muscles, Bones, Joints)
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Other
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Integ. (Skin, Hair & Breast)
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Other
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Neurologic (Brain & Nerves)
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Other
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Psychiatric (Mood & Thinking)
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Other
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Endocrinologic (Glands)
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Other
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Hematologic (Blood/Lymph)
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Other
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Allergic/Immunologic
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Other
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