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What is the reason for your visit today?
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Health Information
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Was this an injury? (click if "Yes")
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Was the injury work related?
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Date of injury?
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Which Physicians do you see regularly?
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Other
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Pain
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Type of Pain
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Please rate your pain level
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Medical History
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CURRENT or PREVIOUS Medical Conditions
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Other
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Surgical History
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Have you had any previous surgeries?
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Please list surgeries with dates:
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Family History
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Father's Medical History
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Comments
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Mother's Medical History
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Comments
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Sibling's Medical History
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Comments
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Social History
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Do you drink alcohol?
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Do you use tobacco products?
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Review of Systems
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Fever or Chills?
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If YES, please explain:
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Chest Pain?
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If YES, please explain:
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Breathing Problems?
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If YES, please explain:
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Headaches?
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If YES, please explain:
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Shortness of Breath?
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If YES, please explain:
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Visual Changes
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If YES, please explain:
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Anxiety?
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If YES, please explain:
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Nausea?
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If YES, please explain:
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Anaphylactic Reaction?
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If YES, please explain:
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Nasal Discharge?
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If YES, please explain:
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Rashes?
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If YES, please explain:
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