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Control’s.Health.Form Form ID #
3082
Space provided to write freely your impressions and make notes!
(None of this text is considered for point calculation.)
Page 1 of 3
Study – Winston Salem, April 4 2009
Control’s.Health.Form Form ID #
3082
PAIN extent JOINT PROBLEMS extent
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Study – Winston Salem, April 4 2009
Control’s.Health.Form Form ID #
3082
Head, headaches, migraine 1 2 3 4 5 Jaw 1 2 3 4 5
Throat or front of neck 1 2 3 4 5 Neck 1 2 3 4 5
Back of neck 1 2 3 4 5 Left Shoulder 1 2 3 4 5
Left shoulder 1 2 3 4 5 Right Shoulder 1 2 3 4 5
Right shoulder 1 2 3 4 5 Left Elbow 1 2 3 4 5
Left arm 1 2 3 4 5 Right Elbow 1 2 3 4 5
Right arm 1 2 3 4 5 Left Wrist 1 2 3 4 5
Left hand or left wrist 1 2 3 4 5 Right Wrist 1 2 3 4 5
Right hand or right wrist 1 2 3 4 5 Left hand Fingers 1 2 3 4 5
Chest area 1 2 3 4 5 Right hand Fingers 1 2 3 4 5
Upper abdomen 1 2 3 4 5 Spine 1 2 3 4 5
Left side of abdomen 1 2 3 4 5 Left side Hip/Thigh joint 1 2 3 4 5
Right side of abdomen 1 2 3 4 5 Right side Hip/Thigh joint 1 2 3 4 5
Lower abdomen 1 2 3 4 5 Left Knee 1 2 3 4 5
Hip or pelvic area 1 2 3 4 5 Right Knee 1 2 3 4 5
Upper back 1 2 3 4 5 Left Ankle 1 2 3 4 5
Middle back 1 2 3 4 5 Right Ankle 1 2 3 4 5
Lower back 1 2 3 4 5 Left Foot or Toes 1 2 3 4 5
Left leg 1 2 3 4 5 Right Foot or Toes 1 2 3 4 5
Right leg 1 2 3 4 5
Left knee 1 2 3 4 5 BONE PROBLEMS extent
Right knee 1 2 3 4 5 Cranium 1 2 3 4 5
Left foot 1 2 3 4 5 Neck vertebrae, collar bone 1 2 3 4 5
Right foot 1 2 3 4 5 Upper back spine 1 2 3 4 5
Heart 1 2 3 4 5 Middle back spine 1 2 3 4 5
Stomach 1 2 3 4 5 Lower back spine 1 2 3 4 5
Other pain, write where 1 2 3 4 5 Chest, ribcage 1 2 3 4 5
Left side Hip and pelvic 1 2 3 4 5
MUSCLE PROBLEMS extent Right side Hip and pelvic 1 2 3 4 5
Facial/Head 1 2 3 4 5 Left Shoulder 1 2 3 4 5
Neck 1 2 3 4 5 Right Shoulder 1 2 3 4 5
Shoulders/Shoulderblades 1 2 3 4 5 Left arm or hand 1 2 3 4 5
Chest 1 2 3 4 5 Right arm or hand 1 2 3 4 5
Upper back 1 2 3 4 5 Left leg or foot 1 2 3 4 5
Middle back/Lower back 1 2 3 4 5 Right leg or foot 1 2 3 4 5
Abdomen 1 2 3 4 5
Left arm/hand 1 2 3 4 5
Right arm/hand 1 2 3 4 5
Left leg/foot 1 2 3 4 5
Right leg/foot 1 2 3 4 5
SPECIAL CONDITIONS extent
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Study – Winston Salem, April 4 2009
Control’s.Health.Form Form ID #
3082
Have you had a fractured bone? Scull/Cranium recent | 6 months | older 1 2 3 4 5
Mark all that apply and mark when Left arm or hand recent | 6 months | older 1 2 3 4 5
they were fractured and the Right arm or hand recent | 6 months | older 1 2 3 4 5
extent (severity) of the fracture. Collarbone recent | 6 months | older 1 2 3 4 5
Rib recent | 6 months | older 1 2 3 4 5
Spine/Back recent | 6 months | older 1 2 3 4 5
Hip recent | 6 months | older 1 2 3 4 5
Left leg or foot recent | 6 months | older 1 2 3 4 5
Right leg or foot recent | 6 months | older 1 2 3 4 5
Have you had any accident or injury with
lasting discomfort, please describe: 1 2 3 4 5
Have you had surgeries, specify 1 2 3 4 5
Implants, pacemaker, screws, staples, 1 2 3 4 5
concealed body piercings,etc. describe:
Large scars, please write where 1 2 3 4 5
Kidney stones 1 2 3 4 5
Heart problem, describe: 1 2 3 4 5
Removed organs left kidney | right kidney
gall bladder | appendix | tonsils
Missing your own natural… upper jaw left side | upper jaw right side
tooth or teeth in what area(s) lower jaw left side | lower jaw right side
(Women) Pregnant first month | 2-5 months | 6-9 months
(Women) Menstruation/Period first half of period |second half of period
(Men) Vasectomy
DISCOMFORTS extent
Any discomfort with eyes left eye | right eye | both eyes 1 2 3 4 5
Permanent ”objects” in field of vision left eye | right eye | both eyes 1 2 3 4 5
Describe their shape, placement and size:
Bad hearing in Left ear 1 2 3 4 5
Bad hearing in Right ear 1 2 3 4 5
Tinnitus (ringing in Left ear) 1 2 3 4 5
Tinnitus (ringing in Right ear) 1 2 3 4 5
Anxiety 1 2 3 4 5
Dizziness 1 2 3 4 5
Confusion 1 2 3 4 5
Do you smoke cigarettes,how often every day | few times a week | more seldomly 1 2 3 4 5
Phlegm in lungs 1 2 3 4 5
Asthma 1 2 3 4 5
Trouble swallowing 1 2 3 4 5
Need to empty bladder 1 2 3 4 5
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