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Reason for visit?*
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Which Side?
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Body part injured/pain:*
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Describe the problem in detail. (What hurts and how injury occured)
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Where is your pain?
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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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Describe the pain:*
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Pain description, other:
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When is the pain the worst?
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Are there any other associated signs or symptoms?
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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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Treatment - Provider and Location
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Treatment - Provider and Location
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Have you had any diagnostic studies done for this problem?
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Imaging Center Name and Location
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Date and Type of Imaging
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Imaging Center Name and Location
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Date and Type of Imaging
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Are there any specific treatment options that brought you to us? (ie. PRP, Stem Cell, Viscosupplementation, PT/OT etc)
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