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Chief Complaint: Initial evaluation of .....
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Date of Injury
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Work / MVA / Personal Injury
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Free Text ->accident type 'from a ...'
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Mechanism of Accident - THE STORY
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Are you currently working?
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If not working, last date worked
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If Yes: Current Job Description
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If No: Prior Job Description
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Pain Level Today
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Average Pain Level Last 7 Days
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When does the pain occur?
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When is the pain the worst? (Free Text)
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When is the pain the least? (Free Text)
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Been Treated by a Pain Doctor Before?
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Pain Treatments Tried By Other Doctor
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Pain Treatments Tried (free text)
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How well are you sleeping?
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ADL Assessment
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ADL Limitations After Injury
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How Long Can You Sit For?
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Minutes Can Sit
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How Long Can You Stand For?
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Minutes Can Stand
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How Long Can You Walk For?
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Minutes Can Walk
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How Many Flights of Stairs Can You Climb?
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Number of Flights of Stairs
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Pain Location #1 is? (Place on body)
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Pain Location #1 Description(pick list)
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Pain Location #1 Description(free text)
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Pain Location #1 Muscle Spasms?
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Pain Location #1 Muscle Spasm?(free text)
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Pain Location #1 Weakness?
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Pain Location #1 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #1 Treatments Tried?
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Treatments tried for Pain Location #1(free text)
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Treatments that helped Location #1
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Treatments that helped Location #1(free text)
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Pain Location #1 General Comments
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Pain Location #2 is? (Place on body)
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Pain Location #2 Description(pick list)
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Pain Location #2 Description(free text)
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Pain Location #2 Muscle Spasms?
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Pain Location #2 Muscle Spasm?(free text)
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Pain Location #2 Weakness?
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Pain Location #2 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #2 Treatments Tried?
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Treatments tried for Pain Location #2(free text)
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Treatments that helped Location #2
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Treatments that helped Location #2(free text)
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Pain Location #2 General Comments
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Pain Location #3 is? (Place on body)
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Pain Location #3 Description(pick list)
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Pain Location #3 Description(free text)
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Pain Location #3 Muscle Spasms?
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Pain Location #3 Muscle Spasm?(free text)
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Pain Location #3 Weakness?
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Pain Location #3 Weakness? (free text)
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Activities that increase Pain (pick list)
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Activities that increase Pain (free text)
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Pain Location #3 Treatments Tried?
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Treatments tried for Pain Location #3(free text)
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Treatments that helped Location #3
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Treatments that helped Location #3(free text)
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Pain Location #3 General Comments
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