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Problem area
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Current synptoms
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First notice symptoms
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There was no acute injury . . .
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Acute injury
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Do these symptoms imapct your daily life?
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How would you describe your pain?
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What makes your pain better?
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What makes your pain worse?
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If you were to need surgery, do you have support?
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Pror care
• • •
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Referring physician name
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Referring physician phone number
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Primary consulted physician
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Primary consulted physician phone number
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Previous type of surgery
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Previous surgeon
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Surgery month
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Surgery year
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Surgery location
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Trigger point injections?
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How many trigger point injections?
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What level of relief did you experience?
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Facet injections?
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How many facet injections have you received?
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What level of relief did you experience?
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Nerve blocks?
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How many nerve blocks?
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What level of relief did you experience?
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Nerve/Radio frequency ablation?
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How many never and or radio frequency ablations have you had?
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What level of relief did you experience?
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Other injections or procedures?
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What medications have you taken for this issue?
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How long did you engage in Physical Therapy?
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What level of relief did you experience?
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How recently was your last session?
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Physical therapist name
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Physical therapist phone number
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Acupuncture? What level of relief?
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Chiropractic? What level of relief?
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Massage therapy? What level of relief?
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Traction/Inversion? What level of relief?
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Tell us about the other treatment options you have tried and the level of relief you experienced for each.
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No imaging studies
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Most recent study type
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Imaging Month
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Imaging Year
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Imaging location
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Med / fam / social history
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Review of Systems
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