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Reasons for Visit
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What brings you in today?
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Left / Right / Both
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Other
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Description of Symptoms
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Quality of Discomfort
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Severity of Discomfort
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Are you getting better, worse or the same?
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How often do you experience symptoms?
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How do you think problem began?
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When did this problem start?
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What makes you better?
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What makes you worse?
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Do you have any of the following?
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Were you hurt at work or in a car accident?
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Short Term Goal
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Long Term Goal
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