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Symptom Survey FormINSTRUCTIONS: E-mail Submission RESPONSE KEY: Please use only these numbers. Leave the entry blank if the symptom does not apply to you. (1) for MILD symptoms (occurring 1-2 times per year), (2) for MODERATE symptoms (occurring many times during the year, (3) for SEVERE symptoms (occurring most of the time) INSTRUCTIONS: Fax Submission Dr. Karl R.O.S. Johnson at (586) 731-9550. (If faxing from outside the United States, don't forget to add the required international dialing prefix for the United States!) RESPONSE KEY: Please use only these numbers. Leave the entry blank if
if the symptom does not apply to you. (1) for MILD symptoms (occurring 1-2
times per year), (2) for MODERATE symptoms
(occurring many times during the year, (3) for SEVERE
symptoms (occurring most of the time)
GROUP ONE
GROUP TWO
GROUP THREE
GROUP FOUR
GROUP FIVE
GROUP SIX
GROUP SEVEN (A)
GROUP SEVEN (B)
GROUP SEVEN (C)
GROUP SEVEN (D)
GROUP SEVEN (E)
GROUP SEVEN (F)
GROUP EIGHT
FEMALE ONLY
MALE ONLY
All finished? Then, press Submit to send the results (by e-mail) to
Dr. Karl R.O.S. Johnson. (Fax submitters should not use this button!) Pressing
Reset will clear the form and allow you to start again.
For more information, please contact Dr. Karl R.O.S. Johnson at the Chiropractic & Nutrition Wellness Center by phone at (586) 731-8840 or by e-mail at info@wellnesschiro.com.
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