9:00 p.m. – 10:0 p.m.
10:00 p.m. – 11:00 p.m.
11:00 p.m. – 12:00 p.m.

Please rate your symptoms or conditions from 1 – 10 based on this scale:

10 – Emergency Room Pain
9 - Extremely Severe
8 - Severe
7 - Somewhat Severe
6 - Moderate To Severe
5 - Moderate
4 - Moderate to Mild
3 - Mild
2 – Mild to Minimal
1 - Minimal
0 - No pain

We need a history of your medical care up to today.

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