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Reason for your visit today
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Primary Care Physician
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Date you first noticed symptoms
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Frequency of Symptoms
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Where does it hurt?
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Other
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Rate your pain level
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What does it feel like?
• • •
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What is your preferred pharmacy?
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Pharmacy phone number?
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Who referred you?
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Anything special we need to know
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Want access to online portal?
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Which specialists do you see?
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Do you use online scheduling?
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Family History - Mother
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Other illnesses or conditions
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Family History - Father
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Other illnesses or conditions
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Family History - Siblings
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Other illness or conditions
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Other hereditary health issues
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Where did you find us?
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