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*Preferred Mode of Contact: Day Phone Cell Phone Night Phone E-mail Hold down the CMD key to select multiple
Symptoms/Concerns: Car crash injury Headaches Migraines Sinusitis Menstrual pain Hormonal imbalance Fatigue Insomnia Depression Stress Fibromyalgia Digestive problems Visual impairments Learning disabilities Other Use the slider to scroll & hold down the CMD key to select multiple issues of concern.
Side effects associated with: Asthma Diabetes Arthritis Cancer Other Hold down the CMD key to select multiple side effects.
Local aches and pains: Back Neck Shoulders Arms Hands Legs Feet Other Use the slider to scroll & hold down the CMD key to select multiple aches and pains.
Stiffness and numbness Back Neck Legs Arms Wrists Elbows Extremities Other Use the slider to scroll & hold down the CMD key to select mulitple locations.
Comments: If you have selected 'Other' above, please explain.
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