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New Patient
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Follow Up Appointment
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Treatment Plan Visit
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Motor Vehicle Accident Care
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Physio Training
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Sports Physical
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Reasons for Visit
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Symptoms
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Head Pain
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What area of your head?
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Describe your head pain?
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Head Pain Level
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(He/She) reported that the pain and dysfunction increased with:
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How often do you have this pain?
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Pain decreases with:
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Comments:
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TMJ (Jaw Pain)
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Describe your Jaw pain?
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Jaw Pain Level
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Pain decreases with:
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How often do you have this pain?
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(He/She) reported that the pain and dysfunction increased with:
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Neck Pain
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Describe your neck pain
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Neck pain level
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Pain and dysfunction increases with:
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How often do you have this pain?
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Pain decreases with:
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Chest Pain
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Which area of your chest?
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Describe your chest pain
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Chest Pain Level
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Pain and dysfunction increases with:
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How often do you have this pain?
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Pain decreases with:
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Back Pain
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Which area of your back?
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Describe your back pain
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Back Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Shoulder Pain
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What area of the shoulder?
• • •
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Describe your shoulder pain/discomfort
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Shoulder Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
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Arm Pain
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What area of your arm(s)?
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Describe your arm pain
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Arm Level Pain
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Pain and dysfunction increases with:
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How often do you have this pain?
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Pain decreases with:
• • •
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Wrist Pain
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Which wrist?
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Describe your wrist pain
• • •
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Wrist pain level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Hand Pain
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Which Arm?/What Area of your Hand?
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Describe your hand pain
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Hand pain level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Hip Pain
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Which hip?
• • •
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Describe your hip pain?
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Hip Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Glute Pain
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Which side?
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Describe your glute pain
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Glute Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
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Leg Pain
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Which area of your leg(s)
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Is there another area of the leg that you want to doctor to know about?
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Which area of your leg?
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Describe your leg pain
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Leg pain level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
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Knee Pain
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What area(s) of the knee
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Describe your knee pain?
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Knee Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
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Ankle Pain
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Which area of your ankle(s)
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Describe your ankle pain?
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Ankle pain level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Foot Pain
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What area(s) of your foot/feet
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Describe your foot/feet pain?
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Foot/Feet Pain Level
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Pain and dysfunction increases with:
• • •
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How often do you have this pain?
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Pain decreases with:
• • •
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Broken/ Fractured Bones
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Where is the broken bones located
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Please Circle the Area of the Body that you are experincing Pain or Discomfort
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Concussion Followup
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Interested in Cranial Facial Release
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Headache
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Facial Questions
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Difficulty Breathing
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Facial Pain
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Dizzy
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