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Here to follow up on:
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I have had:
• • •
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My pain today is a:
• • •
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My pain on a good day is a:
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My pain on a bad day is a:
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Quality of Pain:
• • •
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Radiating Pain:
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If yes, where to?
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Check all that apply:
• • •
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Mark the areas of pain on the diagram:
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Please indicate previous treatments:
• • •
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