SYSTEMS SURVEY FORM

Restricted to Professional Use



Top 5 Main Complaints (in order of importance)

Circle the corresponding number:
1 = MILD symptom (occurs rarely)     2 = MODERATE symptom (occurs several times a month)     3 = SEVERE symptom (occurs almost constantly)

GROUP 1

GROUP 1 Total:

GROUP 2

GROUP 2 Total:

GROUP 3

GROUP 3 Total:

GROUP 4

GROUP 4 Total:

GROUP 5

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GROUP 6

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GROUP 7A

GROUP 7A Total:

GROUP 7B

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GROUP 7C

GROUP 7C Total:

GROUP 7D

GROUP 7D Total:

GROUP 7E

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GROUP 7F

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GROUP 8

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FEMALE ONLY

FEMALE ONLY Total:

MALE ONLY

MALE ONLY Total: