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Oswestry score
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Neck disability index
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Reason for visit
• • •
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Comments
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Since last appointment
• • •
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Comments
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Patient complaints
• • •
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Comments
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Symptom location
• • •
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Symptom location specifics
• • •
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Symptom quality
• • •
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Quality/Descripton Comment
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Associated symptoms
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Associated symptoms comments
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Severity
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Severity comment
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Symptom onset
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Onset Comment
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Symptom trend
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Symptom trend comments
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Specific details
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Specific details comments
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Bowel/bladder
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Bowel/bladder comments
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More details
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MVA
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Industrial
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Work comp insurance carrier
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Work comp claims adjuster
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Work comp claim number
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Attorney
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Attorney name
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More details
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