Questions/Consultation


Symptoms

CHECK A BOX FOR EACH SYMPTOM which best describes how you have been feeling for the past 3 weeks.

  • 0 = None (symptom not present)
  • 1 = Mild (present but not distressing)
  • 2 = Moderate (distressing, but not interfering with daily life)
  • 3 = Severe (very distressing, interferes with daily life)

If you wish to add comments or details, please send by separate email to our pharmacy, indicating your first and last name in the email. Thank you.


Health Questions


Personal Medical History

Please indicate whether you have had any of the following medical problems (with dates).



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