Norse Freedom from pain clinic health Questionnaire


Please fill in your details and then read the questions that follow carefully and answer each one honestly YES or NO 

Do you have high blood pressure?
Is your bowel and bladder function normal?
Do you have a pacemaker?
Do you have metal implants?
Are you on medication?
Are you undergoing any medical treatment?
Have you had any medical surgery?
Are you diabetic?
Please tick as appropriate: Do you have any problems with the following body systems?
Have you had any of the following?

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