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How can we help you?
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When did your problem begin?
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Have you ever had this problem before?
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If yes please explain.
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Is this problem: check all that apply
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Other: Please explain
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What makes your problem BETTER (check all that apply)
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Certain Positions (please explain)
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What makes your problem worse? (check all that apply)
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Certain Positions (please explain)
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Does your pain travel or radiate from one area to another?
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If yes please explain.
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How often are the complaints present?
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Since the problem began the pain has:
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Please list other health concerns you would like addressed.
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On a scale of one to ten, how would you rate your pain
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Please indicate the type of pain you are having.
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Past Medical History
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Name of primary care physician
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Where and when did you last receive health care?
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Approximate date of your last physical
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Approximate date of last blood test
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Approximate date of last Xray/MRI and where it was done
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List any serious trauma you have had in your life such as a car accident or a fall.
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List any major surgeries or hospitalizations you have had in your life.
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Date of last menstural period.
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Are you pregnant?
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Number of pregnancies
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Number of live births
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Past Medical History
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Comments
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Past Surgical History
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Comments
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How would you rate your overall stress level?
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How would you rate your physical activity at work?
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How would you rate your exercise level? (planned activities)
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Diet/Tobacco/Alcohol
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Caffeine
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Alcohol
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Fruits/Vegetables
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Wheat/gluten containing foods (bread, pasta, baked goods)
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Meats (beef, chicken, pork, etc)
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Sugar/ Corn Syrup/ Sugary Drinks and Snacks
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Dairy Products
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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