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Preliminary questionnaire

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    Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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    Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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    Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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    Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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    Please describe how long you have experienced the problem and any medications you are taking for it, or have taken for it.
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    Please give product name, manufacturer, dose and reason for taking
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    Please give product name, manufacturer, dose and reason for taking
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    Please give product name, manufacturer, dose and reason for taking
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    Please give product name, manufacturer, dose and reason for taking
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    Please give product name, manufacturer, dose and reason for taking
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    Please list all that you can remember with approximate dates
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    Please list all that you can remember with approximate dates
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    Please list any tests together with the results if you have them
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    Tick all that apply
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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    Please rate each of the following symptoms
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