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History of injury:
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Date of Injury:
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Chief Complaint:
• • •
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Other complaints, list
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Motor vehicle accident
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Other:
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Position in Car and Where it Was Struck
• • •
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Other:
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Other type of injury
• • •
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Other
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Emergency Room
• • •
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The patient was seen
• • •
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Comments
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Prior injury
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Prior injury details
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Referred from?
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Name of referral source
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