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Which specialists do you see?
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Who referred you to our office?
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What is your main complaint?
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Indicate where you feel the pain
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Rate the severity, 1 mild, 10 severe
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The problem is-
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Relieved By
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Describe the pain's quality
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Aggravated By
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What supplements do you take?
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For women
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Past Surgeries and year performed
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Do you smoke?
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Servings of caffeine per day?
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Alcohol per week
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