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Who is your internist / primary care MD?
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Who referred you to us?
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Right / Left handed
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What is your occupation?
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Please describe your problem in 1-2 sentences
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Was this an acute injury?
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Please describe injury including date
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If no acute injury, how/when did symptoms start?
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List hobbies/activities affected by symptoms
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Please list MD/DC/PT you saw for this problem?
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Have you had recent imaging studies for this problem?
• • •
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When? Where?
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What treatment have you had prior to this visit?
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Have you had injections for these symptoms?
• • •
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When? By whom? How many?
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Please list previous injuries to this body part?
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Additional information you feel is important?
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