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Date of Surgery:
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Types of surgery
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Other:
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Date of injection:
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Types of injection
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Comments
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Has the pain improved since surgery
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Improved from pre op
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Braces, sling, crutches etc
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The patient describes the pain as
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The pain rated at best
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The pain rated at worst
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Currently in therapy?
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Is therapy helping/has it helped
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Medications
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Has medication helped?
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New Short Text Field
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Is the pain constant?
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The pain is made better with
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Other:
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No paresthesias
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Paresthesias?
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Location of paresthesias back and upper extremity
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New Short Text Field
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Location of paresthesias right lower extremity
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Location of paresthesias left lower extremity
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Radiating pain?
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Location of radiating pain back and upper extremity
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Location of radiating pain right lower extremity
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Location of radiating pain left lower extremity
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Comments
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No weakness
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Weakness
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Weakness location
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Comments
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