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Referral Source
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Where did you find us?
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Who referred you?
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Medical History
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Who is your your Primary Care Physician?
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Is it ok to engage with your primary care?
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Pertinent Family History (Yourself Included)
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What other pertinent family history?
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What would you rate your overall health?
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What do you do for exercise?
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What surgical procedures have you had?
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Any physical limitations from complaint?
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Have you had these symptoms previously?
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If so, when?
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COVID QUESTIONNAIRE
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Have you experienced cold or flu like symptoms in the last 14 days?
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Have you had a positive test for COVID-19?
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Have you been in close contact with a confirmed COVID results?
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