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What is your experience of our clinic
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Any additional information about your care recie
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SHOW upper body location HERE
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SHOW Lower body radiation/sensation HERE.
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Chief Complaint what I feel the most now
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Other Complaints/ Secondary Complaint?
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Chief Complaint not listed
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Other/Secondary chief complaint not listed
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Any NEW Trauma (ex. Falls, Auto Accidents)
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No NEW trauma Please go to the next Page
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Please answer any that apply (Legal document)
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Date of Accident
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Describe the Accident in own words
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Were you seen at a Medical Facility after
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If yes Medical facility and address and phone#.
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Weather conditions at the time of accident?
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Road Conditions were best described as:
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Please answer any below Questions
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Describe Your Vehicle Type
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What is your Vehicle Make, Model, Year?
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Vehicle Size?
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Actions of your vehicle:
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Damage to your vehicle is best described as:
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How was your vehicle hit:
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Where was your vehicle hit?
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Describe the second vehicle type?
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What was other Vehicle Make, Model, Year?
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Damage to other vehicle is best described as:
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Body position at time of impact:
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Direction your body was thrown:
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Head position at impact:
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Direction head was thrown:
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Type of restraint:
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Place you were seated in the vehicle:
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Did Airbags deploy?
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Did the seat back bend /break ?
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Any LACERATIONS, CUTS OR BRUISES?
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Other Cuts or Bruises?
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HEAD INJURIES: (now or at accident time)
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JAW PROBLEMS?
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NECK INJURIES
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Other neck injuries not listed
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NECK DIFFICULTIES because of NECK Pain
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Neck issue show HERE
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SHOULDER INJURIES Symptoms
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UPPER ARM PAIN?
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ELBOW PAIN?
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FOREARM symptoms?
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WRIST PAIN?
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HAND PAIN?
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MID BACK PAIN OR UPPER BACK PAIN?
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MID back/Upper Back Area show HERE
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Upper back DIFFICULTIES
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LOW BACK PAIN?
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Low back and Pelvis show HERE
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Low Back/Pelvis Problems b/c of Pain
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PELVIC OR SACRAL PAIN?
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HIP PAIN?
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UPPER LEG PAIN?
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ANKLE PAIN?
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FOOT PAIN?
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KNEE PAIN?
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STOMACH PAIN?
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CHEST PAIN?
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ANY OTHER SYMPTOMS NOT DESCRIBED?
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