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I'M AN ESTABLISHED PATIENT
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I'M A NEW PATIENT
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Yes, Was In Motor Vehicle Collision
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Yes, I Suffered A Concussion
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Yes, I Have Headaches
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Did You Feel Better After Last Treatment?
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Yes
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No
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Temporary Improvement
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How Long Did Improvement Last?
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Feel Worse
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If Yes, Please Describe
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Describe How You Feel Today
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How Do You Feel Today?
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What Has Improved?
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Circle Location Of Pain/Symptoms
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Have You Experienced A Flare Up?
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If Yes, Please Describe
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Rate Your Overall Pain Level
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When Do You Have Pain/Discomfort?
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What Makes Pain/Discomfort Worse?
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What Makes Pain/Discomfort Better?
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Have A New Injury/Complaint?
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Anything Else We Should Know?
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Describe Your Symptoms
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Circle Location Of Pain/Symptoms
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Rate Your OVERALL PAIN Levels
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When Did Symptoms Begin? (mm/dd/yyyy)
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What Caused You Symptoms?
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Describe Your Pain - Select Items
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When Is Pain/Discomfort Elevated?
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What Makes Pain/Discomfort Better?
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What Makes Pain/Discomfort Worse?
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Past History of These Symptoms?
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If yes, when?
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Previously Treated for These Symptoms?
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If So, By Who?
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Motor Vehicle History
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Date Of Motor Vehicle Collision
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Where Was Impact?
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Location of Imact
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Where Was The Motor Vehicle Collision?
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What Were Driving Conditions?
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Where Were You Positioned?
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Were You Wearing A Seatbelt?
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If Driving, How Were You Holding Steering Wheel?
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What Was Head Rest Position?
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Did You Brace For Impact?
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What Was Your Vehicle Doing At Impact?
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Did Your Vehicle Hit Another Structure?
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Experienced Pain/Discomfort Immediately
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Where Did You Experience Immediate Pain?
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Pain/Discomfort Was Delayed?
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Where Did You Experience Delayed Pain?
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Suffered Head Impact
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Did Your Head Hit Any Of These Structures?
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Did You Lose Consciousness?
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What Other Symptoms Did You Experience?
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Emergency Medical Services Called?
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Did Not Go To Hospital
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Did Go To Hospital
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How Did You Get To The Hospital?
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Name Of Hospital/Urgent Care
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What Treatment Was Provided At Hospital?
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Did You Receive Any Diagnostic Imaging?
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What Diagnostic Imaging Did You Receive?
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Have You Been Evaluated or Treated For Injuries
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Have Not Received Prior Treatments
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What Treatments Have You Received?
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Concussion History
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Who Is Filling Out This Form?
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What Type Of Injury?
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Please Describe What Happened
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Where Did Impact Occur?
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Was There Bleeding? Please Describe
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Was There More Than One Blow To Head?
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Please Describe Each Blow To The Head
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Did You Lose Consciousness?
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How Long Were You Unconscious?
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Did You Experience A Seizure?
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Please Describe The Seizure
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What Have You Experienced Following Concussion?
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Additional Information We Should Know?
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Headache History
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Headache Location?
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Headache Severity?
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Frequency of your Headaches?
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Duration of Headache?
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Additional Symptoms With Headaches?
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