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Employer
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Occupation
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How did you hear about our office?
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If Referral, please tell us who?
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If other?
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Current Complaint
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Please list your worst complaint
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How long have you had it
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How did it start?
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A) Are the symptoms (click here)
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B) Rate the pain is it?
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C) What worsens it
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If other, please specify
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D) What makes it better
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If other, please specify
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E) Is it worse in the
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How long have you had it
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F) Describe the symptoms, are they? (click here)
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If other, please specify
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Consent to Treat Minor
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Health History
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Any operations/surgeries or medical procedures
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Date
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Procedure
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Date
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Procedure
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Date
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Procedure
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Serious illnesses/injuries in the past/currently
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Date
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Condition
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Date
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Condition
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Please list any significant family illnesses
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List any medications you are currently taking
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Have you ever had chiropractic care
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If yes, last date of treatment
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By whom
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Results
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Similar or different condition
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Expectations from treatment
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