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Reason for visit?*
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Body part injured/pain:*
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How did the injury occur?
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When did the pain/injury start?
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Exact date if known:
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Pain scale: with activity/injury
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Pain scale: At rest*
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Resumed normal activity*
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Are you back to normal?
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Describe the pain:*
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Pain description, other:
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Is pain better, same or worse?*
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What decreases the pain?*
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Pain decrease, other:
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What increases the pain?*
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Pain increase, other:
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Treatments?*
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Other:
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Any imaging done?*
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Imaging Center?*
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Other location
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