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Women's Health Study

Birthday
Month
Day
Year

All information given in the questionnaire will remain strictly confidential and will only be divulged to the reporting thermographer and any other practitioner that you specify.

Head & Neck

Do you suffer with headaches?
Do you have known allergies?
Do you have TMJ or does your jaw click?
No
Yes
Do you currently have a cold?
No
Yes
Are you being treated for a thyroid disorder?
No
Yes
Do you have neck pain?
No
Yes
Do you have upper back pain?
No
Yes
Do you have a history of carotid artery disease?
No
Yes
Do you have a family history of stroke?
No
Yes
Do you currently suffer with sinus problems?
No
Yes
Do you have history of dental problems?
Have you had a dental cleaning in the past 7 days?
No
Yes
Have you been diagnosed with elevated cholesterol?
No
Yes
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