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Where did you find us?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Which specialists do you see?
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Primary Care Physician
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Past Medical History
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Are you in good health at the present time
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Are you under a doctor's care at the present tim
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Are you taking any medication at the present tim
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Any Allergies to any medications?
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Tobacco use
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Do you suffer from seasonal or food allergies
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History of frequent Headaches?
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Migraines?
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Dizziness or fainting
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History of blood clots/DVT
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Stroke
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High cholesterol
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History of Glaucoma?
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History of Heart Attack or Chest Pain?
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History of High Blood Pressure?
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Do you have ?
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Thyroid disease
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Pacemaker
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Shortness of breath
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Anemia
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History of Diabetes?
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History of Swelling Feet?
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History of liver problems
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Do you have?
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AIDS/HIV
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Patients Kidney problems:
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History of Sleep Apnea
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Hot flashes
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History of cancer
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History of breast or uterine cancer
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Are you extremely fatigued much of the time?
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Libido
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Any Surgery? (non-orthopedic)
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Erectile dysfunction
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Please list any surgeries
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Serious Injuries
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Any unexplained arthritis in various joints?
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Comments
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Any antidepressants?
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Irritability or dramatic changes in behavior?
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