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What are you being seen for today?
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New Patient Visit
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Follow Up Visit
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Which side of the body?
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Which side of the body?
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Location of Injury/Injuries
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Location of Injury/Injuries
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How would you describe the pain?
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What is your pain on a Scale of 0-10?
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How long have you had Symptoms?
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Have your symptoms changed?
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Was this caused by a specific Injury?
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Did you have any new Imaging done (X-Ray/MRI)
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If yes, Please describe what happened
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What kind of Imaging did you have done?
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Date Of Injury
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Where was imaging done?
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Were you seen at an ER or Urgent Care?
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If "other" please type location
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If yes, Which ER or Urgent Care?
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Have you had any treatment since last visit?
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Previous treatment completed
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Treatment completed
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What is your pain on a Scale of 0-10?
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Please fill out the pain diagram
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Please Fill out the Pain Diagram
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