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Today's Date
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Patient Name
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Age
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Marital Status
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Gender
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Social Security (If USA)
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Passport # (If outside USA)
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Home Address
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City
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State
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Zip Code
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Country
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Email
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Home Phone
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Cell Phone
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Occupation
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Work Address
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Work Phone
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Emergency Contact
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Name
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Relationship
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Address
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Home Phone
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Cell Phone
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Work Phone
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Patient Medical History
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Chief Complaint/Reason for appointment
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Severity of pain (1 least - 10 most)
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Location of previous MRI
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Diagnosis and Date of scan
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Location of previous CT Scan
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Diagnosis and Date of Xray
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Location of previous Xrays
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Diagnosis and Date of scan
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Has surgery been recommended?
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If so, what type?
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Previous treatments, surgeries, and results
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Previous treatments, surgeries, and results
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Previous treatments, surgeries, and results
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Previous treatments, surgeries, and results
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Allergies
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If yes, to what?
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Please Name Present Medication
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Pain Medicines
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Steriods
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NSAIDS
• • •
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Blood Pressure
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Cholesterol
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Diabetes
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Vitamins
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Supplements
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Other
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Have you been diagnosed or treated for
• • •
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Any other condition
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Review of System
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Abdominal Bloating
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Abdominal Pain
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Anemia
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Ankle Pain
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Asthma/Wheezing
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Atrial Fibrillation
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Back Pain
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Blood in Urine
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Bloody or tarry stools
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Bruise easily
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Change in bowel habits
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Chest pain - shortness of breath
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Chronic Fatigue
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Constipation
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Cough - fever - chills
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Decrease in flow or force in urination
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Depression
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Diarrhea
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Difficulty with swallowing
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Diptheria - chicken pox
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Dizziness/fainting
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Ear Infections
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Eczema
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Failing vision
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Hair loss
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Frequent infection
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Headaches
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Herpes
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Hip pain
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Knee pain
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Indigestion I heartburn
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Lactose Intolerance
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Leg pain
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Loss of appetite
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Loss of control of urination
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Measles - mumps
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Memory Loss
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Mental Illness
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Muscle weakness
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Nausea
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Neck pain
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Nervousness
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Nosebleeds
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Painful urination
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Prostate disease
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Numbness/tingling
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Rheumatic fever
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Phobias
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Scarlet fever
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Rash
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Shoulder pain
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Ringing in ears
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Swelling
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Sexual dysfunction
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Tremor/shaking
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Sinus trouble
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Urination overnight
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Tick bite
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Weight loss
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Tuberculosis
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Vomiting
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Females please complete
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Other
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Pregnant
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Select Corresponding
• • •
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Date of last period
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Planning
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Pain/bleeding during or after sex
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Days of flow
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Number of live births
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Length of cycle
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Birth Control Method
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Number of abortions
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Date of last mammogram
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Number of miscarriages
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Were the results normal?
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Flushing/Menopause
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Social History
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Smoking
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Cigarettes # of years
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Other # of years
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Alcohol
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Cigars # of years
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Wine # of years
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Beer # of years
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Substance Abuse
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Liquor # of years
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Please specify (Info kept confidential) # of yrs
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Exercise
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Nutrition
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Type
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Family History
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Type
• • •
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Select what diseases are in your family history
• • •
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Is your Mother alive and well?
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Is your Father alive and well?
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If yes, how old is she?
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If not, my condolences. How old was she? Cause?
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Any sisters?
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If yes, how old is he?
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Any brothers?
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If not, my condolences. How old was he? Cause?
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Are they healthy?
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Please rate how your pain disrupts your life?
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Please mark your pain sites on diagram
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