Do you have any Covid symptoms Yes No GDPR Consent I give my consent for my personal data and medical files to be used in this questionnaire. First name* Last Name* Mark the location of your worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord1HiddenYcoord1 HiddenIMGX1HiddenIMGY1Mark the location of your second worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord2HiddenYcoord2 HiddenIMGX2 HiddenIMGY2 Mark the location of your third worst pain with an x Is the pain:Select OneConstantIntermittent three or four times per dayIntermittent once or twice per weekIntermittent once or twice per monthHow bad is the pain on a scale from 1 to 10Select one12345678910HiddenXcoord3HiddenYcoord3 HiddenIMGX3 HiddenIMGY3 HiddenAdministrative Email
