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Where did you find us?
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Who referred you to our office?
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Do you use online scheduling?
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Do you want access to online portal?
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Occupation
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Total Hours/Day: Sitting
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Total Hours/Day: Standing
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Total Hours/Day: Driving
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Total Hours/Day: Walking or Moving
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Reason for Visit
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When did the symtoms appear?
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Is this due to an accident?
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Is yes, what kind of
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If so, Has it been reported to?
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Is the condition getting worse?
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Is it constant?
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What does the pain interfere with?
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The following are Painful/Difficult?
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Comments
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Mark the area of pain
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Do you feel the following:
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Rate your pain 1-10 (10 being the most intense):
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What activities have you stopped doing?
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Have you been treated for this condition before?
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If yes to being treated, what treatment type?
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Date of last exam, Physical:
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Date of Last exam, X-Rays :
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Date of last exam,MRI/CT/Ultra
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Date of Last exam, Blood work:
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Have you had/have the following medical history
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If yes, How often:
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Do you get headaches?
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How do you describe them?
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Are you pregnant?
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If yes, Due date:
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Hormone replacement theraphy?
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Are you taking birth control:
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Have you had surgeries before?
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If yes, please list types of surgeries
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Falls
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If yes, Description
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Date
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Head injuries
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If yes, Description
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Date
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Broken bones
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If yes, Description
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Date
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Auto accident
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If yes, Description
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Date
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Surgeries (please list them)
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Medication allergies (please list them)
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Supplements (please list them)
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Current Medications (please list them)
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