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Attorney Information
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Any other Attorney place here
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Who is your Chiropractor?
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Any other Chiro place here
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What is your date of injury?
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Bodily Injury Complaints
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Characteristics of Pain
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What makes pain better?
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What makes pain worse?
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Pain Scale from 1-10
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What prior treatments have been done?
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Past Surgeries?
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Are you allergic to any medicine?
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Which medication are you allergic to?
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