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Problem Area #1
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Problem Area 1 Pain Level
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Type of Pain
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Since Last Visit?
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Problem Area #2
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Problem Area 2 Pain Level
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Type of Pain
• • •
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Since Last Visit?
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Problem Area #3
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Problem Area 3 Pain Level
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Type of Pain
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Since Last Visit?
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Problem Area #4
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Problem Area 4 Pain Level
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Type of Pain
• • •
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Since Last Visit?
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Pain or Discomfort Affects
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