Acupressure: User Friendly Self Healing |
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This form helps
us determine how acupressure works for you. Please describe as best
you can your condition using this table. Each section is described below. If
they don't seem to relate to your condition write any additional notes that
would help clarify your situation. Follow-up forms will be
sent to you during the next year to measure your results with
acupressure so we can assist you if you are not getting the initial results you desire. Thank you for participating in our research. All
information is confidential and used for research purposes only.
Problem: This term describes the type of problem you are having. This could be pain, depression, infection, fatigue, numbness, disease, or anything else that describes your condition. Be specific like tension headache, cramping pain, pain from burns, etc. Severity: Please use the following number scale to rank how severe your problem was during the last five days. Use any number between 0 to 10 (0 for none to 10 for unbearable). This number will be called severity. Enter it in the box below. 0 1 2
3 4
5 6
7 8
9 10 0 None 2 Mild 4 Bad 6 Very Bad 8 Excruciating 10 Unbearable
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