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Last Name
Email Address
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How much do your symptoms impact your daily life?
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How frequently do you experience symptoms?
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Have you been prescribed opiates?
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What is your age?
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What is your gender?
Do you suffer from any of the following?
Rheumatoid/Psoriatic arthritis
Crohn’s Disease
Multiple sclerosis
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Undergoing treatment for cancer
Undergoing palliative care
Epilepsy
Asthma
Inflammatory Bowel disease
Other condition not listed above
Are you over 18 years of age?
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