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Ten Symptom Quiz

This questionnaire is an important part of providing you with the best healthcare possible. Your answers will help in understanding the problems that you may have. Please answer every question to the best of your ability unless you are asked to skip a section.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

I understand that I should never use this form in an emergency. I understand that, in an emergency, I should dial 911 or go to an emergency department.