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Patient Information
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Last Name
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First Name
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Age
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Occupation
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Sex
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Handedness
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Date of Birth
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Who referred you?
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Which specialists do you see?
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Specialists Names and office #
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What is your preferred pharmacy
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Where did you find us?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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Current Problem
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Reason for visit
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Cause of problem
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Duration of symptoms
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time
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Impacted activities
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Are you taking pain medicine for this?
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Are pain meds effective?
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Any injections to the area?
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# of injections
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Date of last injection
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Have you started physical therapy?
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Have you completed physical therapy
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List any prior shoulder & elbow surgeries with dates
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What is the level of your pain when at its WORST
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What is the level of your pain when at its BEST
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What % function is your shoulder/elbow as of todayl?
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Allergies
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Anxious
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Asthma
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Attention Problems
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Back Problems
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Broken/ Fractured Bones
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Cold
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Cough
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Depression
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Dizzy
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Earache
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Diabetes
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Diarrhea
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Facial Questions
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Heartburn
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Headache
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Shoulder Pain
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Difficulty Breathing
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Neck Pain
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Difficulty Swallowing
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Wrist Pain
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Difficulty Urinating
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Eye Drainage
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Facial Pain
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Fever
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High Blood
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