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CHIRO CONSULTATION
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CHIRO EVALUATION
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ACUP CONSULT/EVAL
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Date of Onset
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No Tx Elsewhere.
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Present History.
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Additional Comments.
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Symptoms Review
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Symptoms Freetype.
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H/A Pain Level [+].
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H/A Location.
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H/A Right/Left.
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H/A Description.
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H/A How Often.
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H/A Duration.
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H/A Provoking.
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H/A What helps?.
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H/A Associated Signs.
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H/A Quick Comments.
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Headache Freetype.
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Neck No Change SLV
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Neck No Complaints or Stiffness.
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Neck Pain Level.
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Neck Pain - Location.
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Neck >R/L or Equal.
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Neck - Description.
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Neck - How Often.
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Neck - Duration.
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Neck - Provoking.
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Neck - What Helps.
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No Relief Statement.
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Free Type/Radiating?
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Mid Back Unchanged SLV
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Mid Back No Pain or Stiffness.
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Mid Back Pain Level
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Mid Back - Pain Location,
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Mid Back - R/L.
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Mid Back - Description.
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Mid Back - How Often,
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Mid Back - Duration.
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Mid Back Provoking,
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Mid Back - What Helps.
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Can also be relieved with ......
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Mid Back Free Type.
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Click On if NOT Radiating
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Mid Back - Rad Description?
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Mid Back Rad Where?
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Radiating Comments Free Type
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Lower Back Unchanged SLV
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Lower Back No Complaints.
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Low Back Pain Level.
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Low Back - Pain Location,
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Low Back - R/L.
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Low Back - Description.
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Low Back - How Often.
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Low Back - Duration.
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Low Back - Provoking.
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Low Back - What Helps.
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ON for NORMAL B/B Function
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Bladder/Bowel Abnormal.
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Free Type/Radiating?
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Complaints - Freetype.
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Complaints - Freetype.
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FRI. Type Score only.
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FRI - Status of Recovery.
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Activity Affected
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General Text
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