Select any health problems
in survey you experience.
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Headaches Migraines Neck Pain
Back Pain Low Back Pain Disc Problems
Arm Pain Hand Pain Shoulder Pain
Hip Pain Leg Pain Foot Pain
Arthritis Bursitis Chronic Pain
Fibromyalgia Muscle Spasms Sprain or Strain
Numbness or Tingling in Hands or Arm
Numbness or Tingling in Feet or Legs
Sports related injury
Automobile Injury
Work related Injury
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| Last Name: |
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| Address: |
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| Phone books used: |
Yellow Book Dex First Choice AT&T Yellow Pages
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What insurance
provider do you use? |
Medicare Blue Cross/Blue Shield
Aetna United Health Care
Cigna Humana
No Insurance
Other Insurance (specify in comment box)
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| What do you enjoy to read? |
Chicago Tribune Chicago Sun Times
Daily Herald Northwest Herald
Arlington Almanac Our Family
Pioneer Press Red Eye Express
Chicago Magazine Northshore Magazine
Other (please specify in comment box)
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