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Please detail each region of your Injuries for medical record
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Neck pain
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Are you experiencing Neck pain?
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Neck pain
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Type of pain
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Average neck pain
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Pain at its worst
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Pain Radiating into the Arm?
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Numbness/ Tingling
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What provokes neck pain?
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Additional Comments:
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What relieves pain?
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Additional Comments:
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Are you experiencing headaches?
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Headache location
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Headache comments
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Concussion and PTSD symptoms
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Medications for injuries:
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Low Back
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Are you experiencing Back pain?
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Back pain
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Type of back pain
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Average back pain
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Pain at its worst
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Pain Radiating into the Leg?
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Numbness/ Tingling
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What provokes Low back pain?
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Additional Comments:
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What relieves pain?
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Additional Comments:
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Medications for injuries:
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Do you have Upper Extremity Injury?
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Upper extremity pain?
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Upper Extremity
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Type of pain
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Average upper extremity pain
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Pain at its worst
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What provokes upper extremity pain?
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What relieves pain?
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Do you have Lower Extremity injury?
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Lower extremity pain?
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Lower Extremity
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Type of pain
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Average Lower extremity pain
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Pain at its worst
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What provokes extremity pain?
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What relieves pain?
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Medical History
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Medical History
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Past Medical History
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Any other significant Medical History?
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Past Surgical History
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Past Spinal or Orthopedic Surgeries
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Comments regarding surgeries
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Primary care doctor?
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Comments
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Allergies
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Disclose Allergies
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Social History
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Social History
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Marital Status
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Occupation
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Do you have Children?
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Comments
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Medical history
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