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Injuries/History (Presiona 'Siguiente' Si Completaste La Previa Página)
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AREAS OF COMPLAINTS
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Please choose your complaints, if any:
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Type any additional complaints you may have (if applicable):
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Upper / Lower Extremity pain / numbness?
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What is your pain level? 10 being the worst.
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Describe your discomfort
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Has your overall condition improved, stayed the same, or worsened?
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How often does your discomfort occur?
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What relieves your discomfort?
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What aggravates your discomfort?
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Systems Review
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Musculoskeletal
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Neurological
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Head & ENT
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Cardiovascular
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Respiratory
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Gastrointestinal
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Genitourinary
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Endocrine
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Dermatological/Hemopoietic
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HISTORY
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Are you pregnant?
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Illnesses/Conditions
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Have you had any surgeries / accident in the past?
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If so, please list your surgeries / accident:
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Are you currently taking medication?
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If so, please list the medications:
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Does the patient smoke?
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Does the patient drink?
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IF YOU WERE IN A CAR ACCIDENT, COMPLETE THE FOLLOWING:
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Type of Accident?
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Date of Accident? (MM/DD/YYYY)
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Where in the vehicle were you?
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Were you wearing a seatbelt?
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Which direction were you looking at the time of the accident?
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Did you hit any of the following vehicle parts?
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Did you hit your head?
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Did you lose consciousness?
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Where was your vehicle hit?
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What direction was your car moving at time of impact?
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Describe your vehicle's damage.
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Was your car towed?
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Was an accident/police report completed?
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Did an ambulance arrive?
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How did you leave the scene?
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Have you seen another provider for this condition?
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